morning report fariz

8/9/2019 Morning Report Fariz

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MORNING

REPORT

Monday, January 19th2015

Case on : Saturday. January 17th2015

Supervisor

dr. Sabar P. Siregar, Sp. KJ


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PATIENTS IDENTITY

Name : Mrs. W

Age : 44 years old

Gender : femaleAddress : Purworejo, Central Java

Occupation : Unemployed

Marriage status: Widow

Last education: Senior high schoolDate of admission: January 17th2015


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ALLOANAMNESIS

Obtained from

Name : S B

Age : 53 years old 35 years old

Gender : female maleRelationship : Sister Brother

Duration of acquaintance : since birth since birth


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REASON BROUGHT TO THE

HOSPITAL

Patient is brought to the hospital by her family

because she was laughing alone, talking to herself,

talked a lot, talk unfocused, sometimes talk using

english speech, her speech that is not understood,

wandering, unable to sleep, very sensitive, anddifficulty eating.


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PRESENT ILLNESS

The patient began to show the symptoms since 1 years ago after

she was divorce with her husband.

After that, she was talked a lot and change of her attitude and

behavior (hyperactive).

6 months later, her mother was died. And then, her symptoms

increased like talking to herself, talked a lot, and talk unfocused.She did not go to work and her social interaction has been

decreasing since the symptoms appear.

1 Month ago, the symptoms began to get worse. She was laughing

alone, talking to herself, talked a lot, talk unfocused, sometimes

talk using english speech, her speech that is not understood,wandering, unable to sleep, very sensitive, difficulty eating, and

she always heard a voice that is not clear in the midnight after

she was praying.

Concerning with her behavior, her sister and her brother took her

to RSJ Magelang.


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PROGRESSION OF ILLNESS

Talked a lot Change of her attitude and behavior (hyperactive)1 year ago

Talking to herself Talked a lot Talk unfocused Social interaction Productivity

6 months ago

Laughing alone Talking to herself Talked a lot Talk unfocused, sometimes talk usingenglish speech

Speech that is not understood Wandering Unable to sleep Difficulty eating She always heard a voiceVery sensitive Social interaction Productivity

1 monthbefore

admission


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HISTORY OF PRESENT ILLNESS

Psychiatric History

She has neverbeen hospitalizeddue to suchpsychiatrycomplaints

General MedicalHistory

Febrile seizure (-) Epilepsy (-) Trauma (-)

Drugs, alcoholabuse, and smoking

history

Alcoholconsumption (-)

Smoking (-) Drug abuse (-)


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STRESSOR

Divorce

Miss her children


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GENOGRAM

= Patient

= Mental Disorders

= Normal

= Died

= Abortus


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FAMILY HISTORY

Her brother have a history of mental illness

Her brother have medication in RSJ Magelang


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PROGRESSION OF DISORDER

symptom

Rolefunction

The day of

admission1 year ago


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HISTORY OF PERSONAL LIFE

1. Prenatal and perinatal history : Normal (good)

2. Early childhood phase : Good

3. ntermediate childhood : Pass in the !enior "igh school and

continue her study in #aculty of $ussiness and management $ut she didn%t

pass it.&. 'ate childhood : Eer or* in roof company as a secretary manager.

!he as ery disciplin $ecause her father is a military person. "er !piritual is

good.

+. ,dulthood : !he has married and she has & children.

!he as diorce $y her hus$and one year ago $ecause her hus$and haing

an a-air ith another girl. !he is ery sensitie if tal* a$out her hus$and.

"er chidren follo her hus$and and lie far aay from her.


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PERSONAL LIFE

#,'/

Patient is the eleenth daughter of 0fteenth si$lings.

"er father passed aay since she as a child.

"er mother passed aay after she diorce ith her hus$and

"er chidren follo her hus$and and lie far aay from her

,t this moment she lies ith her $rother.

P!/"!E45,' "!6R/

,ppropriate ith her gender. !he reali7es that she is a oman.


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PERSONAL LIFE

!EN "!6R/

edium socioeconomic scale

8,'96/

,lloanamnesis : alid


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MENTAL STATE EXAMINATIONON THE DAY OF ADMISSION (SATURDAY, JANUARY 17TH

2015, 10 AM)

Appearance

, female loo*s suita$le ith her actualage ears complete clothes.

State of Consciousness

lear

Speech uantity: increased

uality : decreased


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Behavior

"ypoactie

Hyperactive

Echopra;ia

atatoniaNegatiism

ataple;y

!tereotypy

annerism

,utomatism

ommandautomatism


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Attitude

Cooperative

ndiferrent,pathy

6ension

9ependentPassie

Active

nfantile

9istrust

'a$ileRigid

Passie negatiism

!tereotipyatalepsy

erea >e;i$ility

E;cited


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EMOTION

Mood "ypothymic Euthymic

Elevated

9ysphoric Euphoria E;pansie

Irritable ,gitation

5nremar*a$le

Affect Appropriate nappropriate Restrictie


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Hallucination

Auditory (+)

lfactory (?) 8isual (?) Gustatory (?)6actile (?)

!omatic (?)

Illusion

,uditory (?)

8isual (?) lfactory (?) Gustatory (?)6actile (?)

!omatic (?)

DISTURBANCE OF PERCEPTION

9epersonalisation (?) 9erealisation (?)


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Quantity

Logorrhea


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ontent of 6houghtIdea of Reference

Preoccupation

Obsession

Phobia

Delusion of Persecution

Delusion of Reference

Delusion of Envious

Delusion of Hypochondriac

Delusion of magic-mystic

Fantasy

Delusion of Grandiose

Delusion of Control

Delusion of Influence

Delusion of Passivity

Delusion of Perception

Thought of Echo

Thought Insertion

Thought of withdrawal

Thought Broadcasting

Cant be assesed


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#orm of 6hought

Realistic

Non Realistic

Dereistic

Autistic


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!ensorium and ognition

Level of education: good General knowledge: good

Orientation of T/Pl/Pe/S: good/good/good/good Working/short/long memory: good Writing and reading skills: goodAbility to self care: good


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mpulse ontrol @hen E;amined

Self control:Enough Patient response to examiners question:Enough

nsight mpaired


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EXAMINATION


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H!SICAL E"A#I$A%I&$

onsciousnesss: ompos entis

8ital sign:?


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a. "ead: Normocephaly mouth deiation (?) ,nemic conFungtia (?) icteric sclera (?) pupil isocore

$. Nec*: Normal no rigidity no palpa$le lymphnodes

. 6hora;: or : !1 !2 regular murmur ? gallop ? 'ung : 8esicular sound B hee7ing ?B? ronchi ?B?

d. ,$domen:#lat a$dominal allBBchest all normal peristaltictympany sound tenderness ? mass ? lier spleen and*idney not palpa$le

e. E;tremity : @arm acral capillary re0ll H2I edema (?)some $ruises oer el$os and *nees

RE8E@ !/!6E


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ranial neres e;amination:N : in normal 0nding

N : in normal 0nding

N 88 : in normal 0nding

N 8: in normal 0nding



N 4 : in normal 0ndingN 4: in normal 0nding



NE5RG,' E4,N,6N


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NE5R'G,' !6,65! otori*: Normotonus good coordination of

moement

eningeal sign: negatie

Physiologic re>e; : B

Patologic re>e;: ?B?


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&nset' onth

ago

SI*$IFICA$%FI$I$*S

IFFE,E$%IAL


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IFFE,E$%IALIA*$&SIS

F25.0Schizo-affective Disorders, Manic type

(Skizoafektif tipe manik)

F30.2 Manic with Psychotic Features

(Manik dengan gejala psikotik)


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,;is : #2+.A Schizo-affective Disorders, Manic type

,;is : JA3.2 no diagnosis of a;is

,;is : "ypertension Grade

,;is 8 : 9iorce miss her children

,;is 8 : G,# on admission &A K 31

5'6,4,' 9,GN!!


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1.Problem about patients life (social). 5na$le to hae any normal interaction

. Poor productiity

PR


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2 Problem about patients biological state (biology)

There were imbalance of neurotransmitter.

3.Problem about patients mental state (psychology)

Disturbing towards people surrounding her

She did not control her mood. She always happy and

euforia


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Eergency epartentnF. haloperidol 1 , nF. dia7epam 1 , 8 (sedatie and muscle

rela;ant e-ect)"ospitali7ationris* of damaging herself anddistur$ing people surrounding her

P',NNNG ,N,GEEN6


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%arget %herapy

+AL decrease of symptoms

#aintenance %herapy6a$. 'ithium ar$onat 2AA mg o.12.h.6a$. "aloperidol + mg o.12.h.

6a$. ,mlodipin 1;1Amg

,ES&$SE HASE


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6arget therapy:

? 1AAL remission of symptoms

npatient management:

? ontinuing the pharmacotherapy:

6a$. "aloperidol + mg o.12.h6a$. 'ithium car$onat 2AA mg o.12.h6a$. ,mlodipin 1;1Amg? mproing the patient Muality of life:

6eaching patient a$out her social enironment

(interacting ith her family sociali7ing ith herneigh$or or friends 0nding a ho$$y to do on herspare time)

utpatient management:

? Pharmacotherapy

REMISSION PHASE


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ontinuing the medication control topsychiatric

Reha$ilitation: "elping patient to interact normally ith her family

friends and neigh$or

9oing some actiities that can *eep patient feeloccupied

RECOVERY PHASE


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THANKYOU

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