Download - MORPOTS CONTOH
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SUPERVISOR :DR. SABAR P. SIREGAR, SP. KJ
MORNING REPORTJUNE 4TH 2015
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PATIENT IDENTITY
Name : Mr. BAge : 23 years oldSex : MaleEthnic : JavaneseAddress : TruntungOccupation : PrivateMarital Status : SingleEducation : Senior High School
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ALLOANAMNESIS
Name : Mr. LSex : MaleAge : 52 years oldRelation : Father
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REASON PATIENT BROUGHT TO EMERGENCY ROOM
Patient rampage since one week ago
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STRESSOR
Unknown ( Because there is not valid data)
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PRESENT PSYCHIATRIC HISTORY
Patient has been brought by his father to IGD RSJ Soerojo because he rampage since one week ago. Patient rampage by throwing laptop and bite his father. Patient rampage without any reason. Patient said that he has a power to change the world and also said that he can see “genderuwo” that only he can see and he can communicate to “genderuwo”. Patient said that he has been feeling so happy. Patient difficult to start sleep so he sleep in the middle night but he still feel energic when he woke up.
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IMPAIRMENT
• Since the symptom appear, patient can’t work and take a bath
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PRESENT PSYCHIATRIC HISTORY
One year ago patient has been brought by his father to IGD RSJ Soerojo with the same symptom and admitted for 18 days. He went to Polyclinic routinely until three months after hospitalization. Five years ago, he has been brought to psychiatrist because he afraid to meet new people.
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Drugs, alcohol abuse, and
smoking history
• Head injury (-)• Hypertension (-)• Convulsion (-)• Asthma (-)• Allergy (-)• History of admission (-)
General medical history
• Drugs consumption (-)• Alcohol consumption (-)• Cigarette smoking (+)
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EARLY CHILDHOOD PHASE EARLY CHILDHOOD PHASE (0-3 YEARS OLD)(0-3 YEARS OLD)
Psychomotoric (NO VALID DATA) • There were no valid data on patients growth and
development such as:• 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)• Holding objects in her hand (3-6 months)• Putting everything in her mouth (3-6 months)
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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)
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Emotion (NO VALID DATA) • There were no valid data of patient’s 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 her mother, recognizing 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) • No valid data on when patient’s first time playing hide
and seek or if patient ever involved in any kind of sports.
Psychosocial (NO VALID DATA)• No valid data on how patient socialized with her
surrounding
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Communication (NO VALID DATA) • No valid data regarding patient ability to make
friends at school and how many friends patient have during her school period
Emotional (NO VALID DATA)• No valid data on patient’s adaptation under stress,
any incidents of bedwetting were not known.
Cognitive (NO VALID DATA)• No valid data on patient’s cognitive.
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LATE CHILDHOOD & TEENAGE PHASE
Sexual development signs & activity (NO VALID DATA)• No valid data when patient first experience of
menstruation etc.
Psychomotor (NO VALID DATA) • No valid data if patient had any favourite
hobbies or games, if patient involved in any kind of sports.
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Psychosocial• No valid data
Emotional (NO VALID DATA) • No valid data on patient’s reaction on playing, scared,
showed jealously or competitiveness
Communication • No valid data
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ADULTHOOD
Educational HistorySenior High School
Occupational history He worked as a shopkeeper until one week ago.
Marital StatusSingle
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Criminal HistoryNone
Social Activity No valid data
Current SituationNo valid data
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ERIKSON’S 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
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FAMILY HISTORY
There is no psychiatry history in family
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Male Female Patient Lives together
GENOGRAM
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PROGRESSION OF DISORDER
Symptom
Role function
2010 2014 2015
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MENTAL STATE(TUESDAY 26TH MAY 2015)
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BEHAVIOUR
•Hypoactive•Hyperactive•Echopraxia•Catatonia•Active negativism•Cataplexy•Streotypy•Mannerism•Automatism•Bizarre•Normoactive
•Command automatism•Mutism•Acathysia•Tic•Somnabulism•Psychomotor agitation•Compulsive•Ataxia•Mimicry•Aggresive•Impulsive•Abulia
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ATTITUDE
• Non-cooperative
• Indiferrent• Apathy• Tension• Dependent• Passive
•Infantile•Distrust•Labile•Rigid•Passive negativism•Stereotypy•Catalepsy•Cerea flexibility•Excited
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DISTURBANCE OF PERCEPTION
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THOUGHT PROGRESSION
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CONTENT OF THOUGHT
• 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• Idea of suicide
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FORM OF THOUGHT
•Realistic•Non Realistic•Dereistic•Autism
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SENSORIUM AND COGNITION
Level of education : good General knowledge : good Orientation of time : bad Orientations of place : bad Orientations of peoples : bad Orientations of situation : bad Working/short/long memory : not assessed Writing and reading skills: not assessed Visuospatial : not assessed Abstract thinking : not assessed Ability to self care : good
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PHYSICAL STATUS
Consciousnes : compos mentis Vital sign :
◦Blood pressure : 130/70 mmHg◦Pulse rate : 96 x/mnt◦Respiratory Rate : 24 x/mnt◦Temperature : 36,6 °C
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Head : normocephali
Eyes : anemic conjungtiva -/-, icteric sclera -/-, pupil
isocore , secret (-) , konjungtiva injection (-)
Neck : normal, no rigidity, no palpable lymph nodes
Thorax:
Cor : S 1,2 Sound normal
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill <2”, tremor (-)
Neurological exam : not examined
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RESUME Mental StatusBehaviour: Hyperactive
Mood: Euphoria Perception: auditory and visual hallucination Thought progression: logorrhea, incoherence, sound associationContent of thought: delusion of grandiose, delusion of magic mysticForm of thought: non realistic , autistic
Symptom Impairment
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SYNDROME
InkoherenceAuditory and visual
hallucinationNonrealistic
SCHIZOPHRENIC SYNDROME
HiperactiveEuphoria
LogorrheaGrandiousity
MANIASYNDROME
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DIFFERENTIAL DIAGNOSIS
• F25.0 Schizoaffective Disorder Manic Type• F30.2 Manic with Psychotic Symptoms
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MULTIAXIAL DIAGNOSIS
Axis I : F25.0 Schizoaffective Disorder Manic Type
Axis II : Z03.2 No diagnosisAxis III : No diagnosisAxis IV : He didn’t like mathematics subject in
schoolAxis V : GAF on admission 20-11
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PROBLEM RELATED TO THE PATIENT
1. Psychology ProblemThe patient has introvert personality . Patient had
problems in school, he didn’t like mathematics subject in school.2. Social Problem
- 3. Problem about patient’s biological state
There was an abnormality increase in dopamine and serotonin in mesolimbic .
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PLANNING MANAGEMENT
Inpatient (hospitalization)Purpose of hospitalization is to decrease the symptoms :
Rampage
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RESPONSE PHASE
Target therapy : 50% decrease of symptoms
Emergency department Antipsychotics :
Haloperidol 5 mg IM
Antianxiety : Diazepam for sedative effects and muscle relaxant (IV)
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REMISSION PHASE
Target therapy : 100% remission of symptoms
Inpatient management1. Continue the pharmacotherapy:
Haloperidol 2 x 5 mg OralLithium carbonate 2 x 200 mg Oral
2. Improving the patient quality of life
Outpatient management1. Pharmacotherapy2. Psychosocial therapy
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RECOVERY PHASE
Target therapy : 100% remission of symptom within 1 year.
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THANK YOU