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Morning: Supervisor Dr. Sabar P. Siregar, SP - KJ
Morning: Supervisor Dr. Sabar P. Siregar, SP - KJ
2014
MORNING
REPORT
SUPERVISOR
dr. Sabar P. Siregar, S
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
Stressor
PRESENT HISTORY
2 months ago
Quiet
muting
Talk and laugh by himself
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
General
General
medical
medical
history
history
Drugs
Drugsand
and
alcohol
alcoholabuse
abuse
history
historyand
and
smoking
history
smoking history
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.
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.
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
Basic Conflict
Important Events
Infancy
(birth to 18 months)
Trust vs mistrust
Feeding
Early childhood
(2-3 years)
Toilet training
Preschool
(3-5 years)
Initiative vs guilt
Exploration
School age
(6-11 years)
Industry vs inferiority
School
Adolescence
(12-18 years)
Social relationships
Young Adulthood
(19-40 years)
Intimacy vs isolation
Relationship
Middle adulthood
(40-65 years)
Generativity vs stagnation
Maturity
(65- death)
Reflection on life
FAMILY HISTORY
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.
Socio-economic
Socio-economic history
history
Economic scale
: moderate
Validity
Validity
Alloanamnesis: valid
Autoanamnesis: not valid
Progression of Disorder
2012
Symptom
2010
Role Function
Now
Mental State
31th August 2014
Appearance
Appearance
A male, appropriate to his age,
completely clothed
State
State of
of Consciousness
Consciousness
Disturbed
Speech
Speech
Quantity : Decreased
Quality : Decreased
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
Affect
Affect
Mood
Mood
Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed
Inappropriate
Restrictive
Blunted
Flat
Labile
Disturbance of Perception
Hallucination
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization
(-)
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Derealization (-)
Thought Progression
Quantity
Logorrhea
Blocking
Remming
Mutism
Talk active
Quality
Irrelevant answer
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigration
Perseveration
Sound association
Word salad
Echolalia
Content of Thought
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
Delusion of Envious
Delusion of Hipochondry
Delusion of magic-mystic
withdrawal
Thought of Broadcasting
Form of Thought
Non Realistic
Dereistic
Autistic
Cannot be evaluated
Impulse
Impulse control
control
when
when examined
examined
Self
Self control:
control: enough
enough
Patient
Patient response
response to
to
examiners
examiners question:
question:
good
good
Insight
Insight
Impaired
Impaired insight
insight
Intellectual
Intellectual Insight
Insight
True
True Insight
Insight
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
RESUME
Day of admission
Mental
Impairment
Symptoms
Status
- Mood: Cant be assessed
- Affect: blunted
Quite
Muting
Talk and
laugh by
himself
Perception: Cant be
assessed
Thought Progression:
Mutism
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
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