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 lifePatient 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
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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
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