MORNING REPORT

MORNING REPORT

Sunday morning shift, 31th August 2014

1

Patient Identity

Name : Mr. AS

Sex: Male

Age : 22 years old

Address : Wonosobo

Occupation : Unemployed

Marital State : Unmarried

RELATIVES IDENTITY

Name: Mrs. I

Sex: Female

Age: 52 years old

Relation: Mother

Name: Mrs. P

Sex: Female

Age: 45 years old

Relation: Aunt

Reason patient was brought to emergency room

Patient was quite talking, muting, didnt want to communicate

Stressor

He was forbidden to attend the marriage of his cousin

Present History

Quiet

muting

Talk and laugh by himself

He can not do daily activities normally, for example: eating, bathing, tidy up

Poor utilization of leisure time (sleep)

Couldnt socialize with others

2 months ago

PSYCHIATRIC HISTORY

In 2010, patient had aggressive symptoms such as uncontrolled anger, destructive acting and irritable mood. Patient was being in ward for a month.

In 2012, patient had same symptoms like before. Patient was often to pee in the bed. Patient was being in ward for 3 months.

Day of Admission

31th August 2014

Patient was brought because of:

Quiet

Muting

Talk and laugh by himself

Brought to hospital by his mother and aunt

He cant do his daily activities normally

Poor utilization of leisure time (sleep)

He couldnt socialize with other people

The patient had never seek for a help from a doctor before for this present illness

General medical history

Head injury (+)

Drugs and alcohol abuse history and smoking history

Drugs consumption (-)

Alcohol consumption (-)

Cigarette Smoking (+)

Convulsion (+)

Asthma (-)

Allergy (-)

Hypertension (-)

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Psychomotoric (Suspect Developmental Delay)

- According to his mother, patients growth and development was normal like:

first time lifting the head (3-6 months)

rolling over (3-6 months)

Sitting (6-9 months)

Crawling (6-9 months)

Standing (6-9 months)

walking-running (9-12 months) 20 months

holding objects in her hand(3-6 months)

putting everything in her mouth(3-6 months)

Psychosocial (No Valid Data)

- There were no valid data on which age patient

started smiling when seeing another face (3-6 months)

startled by noises(3-6 months)

when the patient first laugh or squirm when asked to play, nor playing claps with others (6-9 months)

Communication (NO VALID DATA)

- There were no valid data on when patient started bubbling. (6-9 months)

Emotion (NO VALID DATA)

- 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 (NO VALID DATA)

- There were no valid data on which age the patient can follow objects, recognizing his mother, recognize his family members.

- There were no valid data on when the patient first copied sounds that were heard, or understanding simple orders.

11

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor (NO VALID DATA)

No valid data on when patients first time playing hide and seek or if patient ever involved in any kind of sports.

Psychosocial

Patient was known as an obedient boy, and never be a burden to his parent

Communication

Patient was introvert and couldnt make many friends.

Emotional (NO VALID DATA)

No valid data on patients emotional.

Cognitive

Patient didnt pass first grade in elementary school, after that patient didnt continue his formal education. There was no informal education also.

12

LATE CHILDHOOD & TEENAGE PHASE

Sexual development signs & activity

No data on when patient first experience of wet dreams. According to his mother, patient had ever mentioned that he liked a woman.

Psychomotor

Patient favourite hobbies is singing and can play guitar. He cant write and read.

Psychosocial

Patients started growing up introvert and not much talking

Emotional

He was very close to his mother, and looked like a dependent boy.

Communication

Patient has just few friends, uncommunicative, and not much going out.

13

ADULTHOOD

Educational History

He didnt pass first grade in elementary school because he wasnt able to catch up the lesson

Occupational history

He helped his mother for feeding chickens.

Marital Status

Unmarried

Criminal History

No criminal hsitory

Social Activity

Before he was sick, he already had few friends and difficult to make new friends

He never joined any social event.

Current Situation

He lives with his father and older brother. His mother worked in Jakarta. Everyday he like to visit his aunt house and sometime acts childish to his aunt as mother.

14

Eriksons stages of psychosocial development

StageBasic ConflictImportant EventsInfancy(birth to 18 months)Trust vs mistrustFeeding Early childhood(2-3 years)Autonomy vs shame and doubtToilet trainingPreschool(3-5 years)Initiative vs guiltExplorationSchool age(6-11 years)Industry vs inferioritySchoolAdolescence(12-18 years)Identity vs role confusionSocial relationshipsYoung Adulthood(19-40 years)Intimacy vs isolationRelationshipMiddle adulthood(40-65 years)Generativity vs stagnationWork and parenthoodMaturity(65- death)Ego integrity vs despairReflection on life

Patient is the 2nd child of 4 siblings

There is psychiatry disorder in family history, known as his uncle.

FAMILY HISTORY

16

Genogram

Female

Male

Dead

Patient

Mental disorder

Live in one house

PSYCHOSEXUAL HISTORY

Patient realizes that he is male, and has interests to female. His attitude is appropriate as a male.

18

Socio-economic history

Economic scale: moderate

Validity

Alloanamnesis: valid

Autoanamnesis: cant be assessed

Progression of Disorder

Symptom

Role Function

2010

Now

2012

Mental State 31th August 2014

Appearance

A male, appropriate to his age, completely clothed, poor self care

State of Consciousness

Apatis

Speech

Quantity : Decreased

Quality : cant be assessed

BEHAVIOUR

Hypoactive

Hyperactive

Echopraxia

Catatonia

Active negativism

Cataplexy

Streotypy

Mannerism

Automatism

Bizarre

Command automatism

Mutism

Acathysia

Tic

Somnabulism

Psychomotor agitation

Compulsive

Ataxia

Mimicry

Aggresive

Impulsive

Abulia

-echopraxia : pengulangan gerakan yang sama oleh pasien meniru gerakan pemeriksa

-catatonia : perilaku catatone, mempertahankan gerakan aneh

-active negativisme : tahanan tanpa motivasi untuk menggerakkan (memberontak, melawan gerakan)

-cataplexy : penurunan tonus otot karena konflik psikologis

-stereotypy : pergerakan/pembicaraan yang terfiksasi dan berulang-ulang

-mannerism : pengulangan gerakan yg tidak disadari dan menjadi kebiasaan

-automatism : tindakan yang otomatis/spontan, biasanya mewakili aktivitas simbolik yang tidak disadari

-bizarre : aneh

-command automatism : melakukan apa yg diperintahkan secara otomatis

-mutism : pasien tidak mau bicara

-impulsive : dari keadaan diam lalu tiba2 melakukan sesuatu yg dia ingin dan langsung dilakukan

22

ATTITUDE

Indiferrent

Apathy

Tension

Dependent

Passive

Infantile

Distrust

Labile

Rigid

Passive negativism

Catalepsy

Cerea flexibility

Excited

-excited: agitated, purposeless motor activity without external stimuli

23

Emotion

Inappropriate

Affect

Euthymic

Mood

Restrictive

Blunted

Flat

Labile

Elevated

Euphoria

Expansive

Irritable

Cant be assesed

Dysphoric

Agitation

Disturbance of Perception

Depersonalization (-)

Derealization (-)

Auditory (-)

Illusion

Auditory (-)

Hallucination

Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Thought Progression

Quantity

Logorrhea

Blocking

Mutism

Talk active

Quality

Incoherence

Flight of idea

Loosening of association

Neologisme

Circumtansiality

Sound association

Word salad

Echolalia

Tangential

Verbigration

Perseveration

Irrelevant answer

Confabulation

Remming

Poverty of speech

Cant be assessed

Content of Thought

Can not be assessed

Idea of Reference

Idea of Guilt

Preoccupation

Obsession

Phobia

Delusion of Persecution

Delusion of Reference

Delusion of Envious

Delusion of Hipochondry

Delusion of magic-mystic

Delusion of grandiose

Delusion of Control

Delusion of Influence

Delusion of Passivity

Delusion of Perception

Delusion of Suspicious

Thought of Echo

Thought of Insertion & withdrawal

Thought of Broadcasting

Form of Thought

Non Realistic

Dereistic

Autistic

Cannot be evaluated

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Sensorium and Cognition

Level of education: Cant be assessed

General knowledge: Cant be assessed

Orientation of time : Cant be assessed

Orientations of place: Cant be assessed

Orientations of people: Cant be assessed

Orientations of situation: Cant be assessed

Working/short/long memory: Cant be assessed

Writing and reading skills: Cant be assessed

Visuospatial: cant be accessed

Abstract thinking: cant be accessed

Ability to self care: Poor

Impulse control when examined

Insight

Self control: enough

Impaired insight

Intellectual Insight

True Insight

Patient response to examiners question: Poor

Physical State

Consciousnes : compos mentis

Vital sign :

Blood pressure: 125/80 mmHg

Pulse rate : 98x/mnt

Temperature : Afebrile

RR: 16 x/mnt

Review System

Head : normocephali, mouth deviation (-)

Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocore

Neck : normal, no rigidity, no palpable lymph nodes

Thorax :

Cor : S 1,2 regular

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

Abdomen : Pain (-) , normal peristaltic, tympany sound

Extremity : Warm acral, capp refill