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Sunday morning shift, 31th August

2014

MORNING
REPORT

Patient Identity
Name
Sex
Age
Address
Occupation
Marital State

:
:
:
:

Mr. AS
Male
22 years old
Wonosobo
: Unemployed
: 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
2 months ago

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

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
Brought to
hospital by
his mother
and aunt

The patient had never


seek for a help from a
doctor before for this
present illness

Patient was brought


because of:
Quiet
Muting
Talk and laugh by
himself

He cant do his daily activities


normally
Poor utilization of leisure time
(sleep)
He couldnt socialize with other
people

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)


Psychomotoric
Psychomotoric (Suspect
(Suspect Developmental
Developmental Delay)
Delay)
-- According
According to
to his
his mother,
mother, patients
patients growth
growth and
and development
development was
was
normal
normal like:
like:
first
first time
time lifting
lifting the
the head
head (3-6
(3-6 months)
months)
rolling
rolling over
over (3-6
(3-6 months)
months)
Sitting
Sitting (6-9
(6-9 months)
months)
Crawling
Crawling (6-9
(6-9 months)
months)
Standing
Standing (6-9
(6-9 months)
months)
walking-running
walking-running (9-12
(9-12 months)
months)
20
20 months
months
holding
holding objects
objects in
in her
her hand(3-6
hand(3-6 months)
months)
putting
putting everything
everything in
in her
her mouth(3-6
mouth(3-6 months)
months)
Psychosocial
Psychosocial (No
(No Valid
Valid Data)
Data)
-- There
There were
were no
no valid
valid data
data on
on which
which age
age patient
patient
started
started smiling
smiling when
when seeing
seeing another
another face
face (3-6
(3-6 months)
months)
startled
startled by
by noises(3-6
noises(3-6 months)
months)
when
when the
the patient
patient first
first laugh
laugh or
or squirm
squirm when
when asked
asked to
to play,
play, nor
nor
playing
playing claps
claps with
with others
others (6-9
(6-9 months)
months)

Communication
Communication (NO
(NO VALID
VALID DATA)
DATA)
-- There
There were
were no
no valid
valid data
data on
on when
when patient
patient started
started bubbling.
bubbling.
(6-9
(6-9 months)
months)
Emotion
Emotion (NO
(NO VALID
VALID DATA)
DATA)
-- There
There were
were no
no valid
valid data
data of
of patients
patients reaction
reaction when
when playing,
playing,
frightened
frightened by
by strangers,
strangers, when
when starting
starting to
to show
show jealousy
jealousy or
or
competitiveness
competitiveness towards
towards other
other and
and toilet
toilet training.
training.
Cognitive
Cognitive (NO
(NO VALID
VALID DATA)
DATA)
-- There
There were
were no
no valid
valid data
data on
on which
which age
age the
the patient
patient can
can
follow
follow objects,
objects, recognizing
recognizing his
his mother,
mother, recognize
recognize his
his family
family
members.
members.
-- There
There were
were no
no valid
valid data
data on
on when
when the
the patient
patient first
first copied
copied
sounds
sounds that
that were
were heard,
heard, or
or understanding
understanding simple
simple orders.
orders.

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)


Psychomotor
Psychomotor (NO
(NO VALID
VALID DATA)
DATA)

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

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

Patient
Patient was
was introvert
introvert and
and couldnt
couldnt make
make many
many friends.
friends.
Emotional
Emotional (NO
(NO VALID
VALID DATA)
DATA)

No
No valid
valid data
data on
on patients
patients emotional.
emotional.
Cognitive
Cognitive

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

LATE CHILDHOOD & TEENAGE PHASE


Sexual
Sexual development
development signs
signs &
& activity
activity

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

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

Patients
Patients started
started growing
growing up
up introvert
introvert and
and not
not much
much talking
talking
Emotional
Emotional

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

ADULTHOOD

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

Occupational
Occupational history
history
He
He helped
helped his
his mother
mother for
for feeding
feeding chickens.
chickens.

Marital
Marital Status
Status
Unmarried
Unmarried

Criminal
Criminal History
History
No
No criminal
criminal hsitory
hsitory

Social
Social Activity
Activity
Before
Before he
he was
was sick,
sick, he
he already
already had
had few
few friends
friends and
and difficult
difficult to
to

Eriksons stages of psychosocial


development
Stage

Basic Conflict

Important Events

Infancy
(birth to 18 months)

Trust vs mistrust

Feeding

Early childhood
(2-3 years)

Autonomy vs shame and


doubt

Toilet training

Preschool
(3-5 years)

Initiative vs guilt

Exploration

School age
(6-11 years)

Industry vs inferiority

School

Adolescence
(12-18 years)

Identity vs role confusion

Social relationships

Young Adulthood
(19-40 years)

Intimacy vs isolation

Relationship

Middle adulthood
(40-65 years)

Generativity vs stagnation

Work and parenthood

Maturity
(65- death)

Ego integrity vs despair

Reflection on life

FAMILY HISTORY

Patient is the 2nd child of 4 siblings

There is psychiatry disorder in


family history, known as his uncle.

Genogram

Femal
e
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.

Progression of Disorder
2012

Symptom
2010

Role Function

Now

Mental State
31th August 2014

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

ATTITUDE

Indiferrent
Apathy
Tension
Dependent
Passive

Infantile
Distrust
Labile
Rigid
Passive negativism
Catalepsy
Cerea flexibility
Excited

Emotion

Disturbance of Perception

Depersonalization
(-)

Derealization (-)

Thought Progression

Content of Thought

Can not be assessed

Delusion of grandiose

Idea of Reference

Delusion of Control

Idea of Guilt

Delusion of Influence

Preoccupation

Delusion of Passivity

Obsession

Delusion of Perception

Phobia

Delusion of Suspicious

Delusion of Persecution

Thought of Echo

Delusion of Reference

Thought of Insertion &

Delusion of Envious

Delusion of Hipochondry

Delusion of magic-mystic

withdrawal
Thought of Broadcasting

Form of Thought
Non Realistic
Dereistic
Autistic
Cannot be evaluated

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

Physical State

Consciousnes
Consciousnes :: compos
compos mentis
mentis

Vital
Vital sign
sign ::

Blood
Blood pressure
pressure :: 125/80
125/80 mmHg
mmHg
Pulse
:: 98x/mnt
Pulse rate
rate
98x/mnt
Temperature
:: Afebrile
Temperature
Afebrile
RR
:: 16
RR
16 x/mnt
x/mnt

Review System
Head
Head
Eyes
Eyes

::normocephali,
normocephali,mouth
mouth deviation
deviation (-)
(-)
::anemic
anemic conjungtiva
conjungtiva(-),
(-),icteric
ictericsclera
sclera (-),
(-),pupil
pupilisocore
isocore

Neck
Neck ::normal,
normal,no
norigidity,
rigidity,no
no palpable
palpablelymph
lymphnodes
nodes
Thorax
::
Thorax
Cor
Cor

::SS1,2
1,2regular
regular

Lung
Lung ::vesicular
vesicularsound,
sound,wheezing
wheezing-/-,
-/-,ronchi-/ronchi-/ Abdomen
Abdomen ::Pain
Pain(-)
(-),,normal
normal peristaltic,
peristaltic,tympany
tympanysound
sound
Extremity
Extremity ::Warm
Warmacral,
acral,capp
capprefill
refill<2,
<2,edema
edema(-)
(-)
Neurological
Neurologicalexam
exam::not
notexamined
examined

RESUME

A man, 22 years old, appropriate


according to his age,
Reason to be brought to hospital are
being quite, muting, talk and laugh by
himself since 2 month ago.
He cant do his daily activities, poor
utilization of leisure time, he couldnt
socialize with other people

RESUME
Day of admission
Mental
Impairment
Status
- Mood: Cant be assessed
- Affect: blunted

Quite
Muting
Talk and
laugh by
himself

Perception: Cant be
assessed

Thought Progression:
Mutism

- Content of Thought: Cant


be assessed
- Form of thought: Autistic
- Patients response to
question: Poor
- Impaired insight

He cant do his
daily activities
Poor utilization
of leisure time
he couldnt
socialize with
other people

Differential Diagnosis
F20.5 Residual Schizophrenia
F71 Moderate Mental Retardation
F60.1 Schizoid Personality disorder

Multiaxial Diagnosis
Axis I

Axis
Axis
Axis

Axis

: F20.5 Residual schizophrenia


Z55.8 Problem in education and
reading
II : F60.1 Schizoid personality type
F60.7 Dependent personality type
III: No diagnosis
IV
: have no friends, poor
communication to others, his
mother works far away from
patient
V
: GAF admission 30-21
GAF last one year 80-71

PROBLEM RELATED TO THE PATIENT

Patient wasnt able to continue formal education


due to his cognitive ability
Patient who is dependent to his mother, lives far
away from her
Patient may not do socialize with other people

PLANNING
PLANNING MANAGEMENT
MANAGEMENT
Inpatient (hospitalization)

RESPONSE
RESPONSE PHASE
PHASE
Target therapy : 50% decrease of symptoms :
Quiting, muting, laughing and speaking by himself
Emergency department
Haloperidol
5mg i.m
Maintance
Haloperidol 2x5mg
Re-assess patient

REMISSION
REMISSION PHASE
PHASE
Target therapy :
100% remission of symptom
Inpatient management
1. Continue the pharmacotherapy: maintenance
Haloperidol 2x5mg
2. Improving the patient quality of life :
Teach patient about his social & environment
(interact with his parents, socialize with his neighbor,
get a new job, find a hobby to do his spare time)
Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy

RECOVERY
RECOVERY PHASE
PHASE
- Continue the medication, control to
psychiatric
- Rehabilitation : help patient to find a
hobby, help patient to interact normally
with his family and neighbor
Family education :
explain to the family about the mental
disorder and the treatment.
- Educate the family to support not to exile
the patient.
- Ask the family to monitor patient progress
and make sure the patient take medicine
Target
therapy : 100% remission of symptom
as prescribe.
Target
therapy : 100% remission of symptom
within 1 year.
within 1 year.
-

THANKS

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