Morpot Ari Fian

8/22/2019 Morpot Ari Fian

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MORNING REPORT

Friday, july 19th 2013

Supervisor : dr Sabar P Siregar Sp.KJ


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Patients Identity

Name : Mr. W

Age : 32 years old

Gender : Male

Address : Purworejo

Occupation : UnemployedMarriage status : Single

Religion : Moslem

Last education : STM

AlloanamnesisName : Mrs. P

Age : 60 years old

Relation : mother


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REASON OF VISIT TO HOSPITAL

Patient get angry this morningand he broke his neighbors

window.


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Presenting illness

2001

- Didnt wantto go out

- Talk less

2007


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The day of admission

RageHis father often yelling at him

Loss of appetite

Less eye contact

Talk less and slowly

Poor self grooming


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HISTORY OF PRESENT ILLNESS

Psychiatry history

Yes, 6 years ago

General medicalhistory

Hypertension (-)

Head injury (-)

Convulsion (-)

Asthma (-)

Allergy (-)

Drugs and alcoholabuse history and

smoking history

Alcoholconsumption (-)

Drugs abuse (-)


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History of Personal Life

PRENATAL AND PERINATAL HISTORY

No valid data whether the mother has sufficient nutricient during

pregnancy and routine vitamin capsule during pregnancy

No valid data whether she has stabile emotional condition during

this pregnancy

No valid data whether every month she goes to primary health

care to check her pregnancy

No valid data whether she has no significant medical problemsuch as profuse vomitus , fever, high blood pressure, seizure,

leukorea and bleeding


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Early Childhood Phase (0-3 years old)

Psychomotoric There were no valid data on patients growth and development such

as: first time lifting the head, rolling over, sitting, crawling, standing,

walking-running, holding objects in her hand, putting everything in

her mouth, holding objects in her hand

Psychosocial

There were no valid data on which age patient started smiling when

seeing another face, startled by noises, when the patient first laugh

or squirm when asked to play, nor playing claps with others

Communication There were no valid data on when patient started saying words like

mom or dad, or talks.


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Emotion

There were no valid data of patients reaction when playing,

frightened by strangers, when starting to show jealousy or

competitiveness towards other and toilet training.

Cognitive There were no valid data on which age the patient can follow

objects, recognizing her mother,recognize her family members.

There were no valid data on when the patient first copied sounds

that were heard, or understanding simple orders


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Intermediate Childhood (3-11 years old)

Psychomotor

No valid data on when patients first time riding a tricycle or bicycle, if patient

ever involved in any kind of sports.

Psychosocial

There were no data on patients gender identification, interaction with her

surroundings

There were no data on when patient first entered primary school, how wellpatient handles seperation from parents, how well she plays with new friends on

first day of school

Communication

There were no valid data regarding patients ability to make friends in school, and

how many friends patient have during her schooling period.

Emotional

No valid data on patients adaptation under stress, any incidents of bedwetting

were not known.

Cognitive

No valid data on patients achievement in school, how well patient;s reading

ability and grades.


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Late Childhood & Teenage Phase

Sexual development signs & activity

No valid data on when patient experience wet dream, hair on armpits and pubis,etc

Psychomotor

No valid data if patient had any favourite hobbies or games, if patient involved in

any kind of sports.

Psychosocial

No valid data if while growing up did he make many friends, how well patient

make any friends and how much friends.

No valid data on when and how patients relationship with different gender, if

patient ever had any relationship with the opposite gender.

Emotional

No valid data if patient ever told friends or family regarding any problems.

No valid data if patient attempted to break the rules (truant schools subject, fight

with friends, bullying, etc) and consuming alcohol, smoke and drugs

Communication

No valid data on how well the relationship between patient with parents and other

family.


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Adulthood

Educational historyPatient has graduated from

high school

Occupational

historyUnemployed (never)

Marriage status

Single

Legal historyNo data

Social activitypatients withdrew from his social

activity

Current situationHe lived with his parents and siblings

Religion historyHe prays everyday until now

He didnt follow any religion

organization


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Family History

Patient is the 1st child from 5 siblings

He lived with his parents, one brother, and

one sister.

In his family his first younger brother has

mental disoder history.


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Psychosexual history

Patient psychosexual history is appropriate

of his gender and attracted to woman


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Genogram


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Socio-economic history

Economic scale: low

Validity

Alloanamnesis : valid

Autoanamnesis : valid


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Progression of Ilness

symptom

Rolefunction

2001 2007 2013


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Mental State ( Friday 19 July 2013)

Appearance :

Man, appropriate according to age, poor grooming

State of Consciousnessclear

Speech:

Quantity: decrease

Quality : decrease


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Behaviour

Hypoactive

Hyperactive

Echopraxia

Catatonia

Active negativismCataplexy

Streotypy

Mannerism

AutomatismBizzare

Command automatismMutism

Acathysia

Tic

SomnabulismPsychomotor agitation

Compulsive

Ataxia

Mimicry

Aggresive

Impulsive

Abulia


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ATTITUDE

Cooperative

Non-cooperative

Indiferrent Apathy

Tension

Dependent

Active

Passive

Infantile

Distrust

Labile

RigidPassive negativism

Stereotypy

Catalepsy

Cerea flexibilityExcitement


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Emotion

Mood

Euthymic

Hipothym Dysphoric

Euphoria

Elevated

Expansive Irritable

Cant be assesed

Affect

Appropriate Inappropriate

Restrictive

Blunted

Flat Labile


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Disturbance of perception

Hallucination

Auditory (-)

Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Illusion

Auditory (-)

Visual (-) Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Derealisation (-)Depersonalisation (-)

Thi ki


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Thinking

thought progression

Quantity

Logorrhea

Blocking

RemmingMutisme

Talk active

Quality

Irrelevant answer

Coherence

Flight of idea

Confabulation

Poverty of speech

Loosening of association

Neologisme

CircumstansialityTangentiallity

Verbigration

Sound association

Perseveration

Word salad

Echolalia


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Thought Process content of thought

Idea of reference

Preokupasi

Obsesi

Fobia

Delution of pursued

Delution of suspicious

Delution of envious

Delution of hipokondri

Delusion of magic-mistic

Delusion of control

Delusion of influence

Delusion of passivity

Delusion of perception

Delusion of grandeur

Thought of echo

Thought of insertion/withdrawal

Thought of broadcasting


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Thought process

Form of Thought

Realistic

Non RealisticDereistic

Autistic


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Sensorium and Cognition

Level of education : enough

General knowledge : enough

Orientation of time/place/people/situation:

enough Working/short/long memory: enough

Writing and reading skills : enough

Visuospatial : enough

Abstract thinking : enough

Ability to self care : enough


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goodImpulse

control whenexamed

Impaired insight Intelectual Insight

True Insight (4)

Insight


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Internal Status

Conciousnes: compos mentis

Vital sign:

Blood pressure : 160/90 mmHg

Pulse rate : 104 x/mnt

Temperature : afebris

RR : 20 x/mnt


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Head: mesocephali

Eyes: anemic conjungtiva -/-, ikteric sclera -/-, pupil isocor

Neck: normal, no rigidity, no palpable lymphnode

Thorax:

Cor: S1 and S2 sound and normal

Lungs: vesicular sound, wheezing -/-, ronchi-/-

Abdomen: pain -, peristaltic normal, thympany sound

Extremity: acral temperature, cappillary refill < 2 second


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SIGNIFICANT FINDING RESUME

Onset: yesterday morning

Symptoms

- Loss of appetite

- Deteriorate self

grooming- Rage

Disability

Poor selfgrooming

Mental StatusCooperative

Mood :elevated

Afect: flat,inappropriate

Stereotypy

Remming

hallucination and delusion ()


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Differential Diagnose

F20.3 Schizophrenia Residual

F 20.4 Depression post Schizophrenia


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Multiaxial Diagnose

Axis I : F20.3 Schizophrenia Residual

Axis II : R 46.8 delayed axis II

Axis III : No diagnosis

Axis IV : His father often yelling at him

Axis V : GAF admission 40


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Therapy

Hospitalization To establish an effective association between patients and

community support systems

Hospital treatment plans should be oriented toward practicalissues of self-care, quality of life, employment, and social

relationships.

FAMILY EDUCATION :

- explain to the patient about test results.

- explained to the patient's family know about this :

1. Help if the patient need help but not passive2. Not too much advise

3. Families must understand the patient


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Medicamentosa :

Lodomer inj 1 amp 10 mg

Diazepam inj 1 amp 5 mg

Haloperidol 2x5 mg ROOM

IGD


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THANK YOU

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Morpot Ari Fian