morport 300514
TRANSCRIPT
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SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ
MORNING REPORT
Tuesday, 30thMay 2014
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Name : Mr. R Sex : Male
Age : 25years old Address :Grabak, Magelang Occupation : Farmer
Marital State : Married
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Name : Mr. A
Sex : Male
Age : 57 years old
Relation : Father
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Patient did committe suicide andunable to sleep
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Patient felt he cant do his obligation
as a husband. Patient said his wifehaving an affair with his neighbourand put Talak to his wife.
Guilty to the Goverment
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The patient was
brought to the ER
His family wasnt
bring the patient to
hospital.
Stay alone in his
bedroom, feel guilty,committe suicide,
descreased appetite
Patient suspect his wife
having an affair with his
neighbor
Feel guilty
Trouble sleeping
27thMay 2014
30thMay 2014
2013
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30thMay 2014
Patient brought with the
complaints of:
Committe suicideUnable to sleep
Brought to
hospital by his
father
The patient didnt go to work
Leasurely time is used to daydream only
Decreased appetite
Didnt socialize with his family/others
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No Psychiatric History
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Generalmedical history
Head injury (-)
Hypertension (-)
Convulsion (-)Asthma (-)
Allergy (-)
Drugs and alcohol
abuse history andsmoking history
Drugs consumption (-)
Alcohol consumption (-)
Cigarette Smoking (+)
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Psychomotoric
- 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)
Psychosocial- 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)
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Communication
- There were no valid data on when patient started bubbling. (6-9 months)
Emotion
- There were no valid data of patientsreaction when playing, frightened
by strangers, when starting to show jealousy or competitiveness
towards other and toilet training.
Cognitive
- 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.
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Psychomotor
No valid data on when patientsfirst time playing hide and seek or ifpatient ever involved in any kind of sports.
Psychosocial
No valid data regarding patient psychosocial.
Communication No valid data regarding patient ability to make friends at school and
how many friends patient have during his school period
Emotional
No valid data on patientsemotional.Cognitive
No valid data on patientscognitive.
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Sexual development signs & activity
No data on when patient first experience of wet dream, etc.
Psychomotor
No data if patient had any favourite hobbies or games, if patient involved in
any kind of sports.
Psychosocial
No valid data regarding patient psychosocial.
Emotional
No valid data on patientsemotional.
Communication
No valid data regarding patient ability to make friends at school and how
many friends patient have during his high school period
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Educational Historyfinished Junior high school
Occupational history
He was a farmer. He didntwork about 3 days, because
he feel exhausted to go to
work.
Marital Status
He has married
Criminal History
KDRT
Social Activity
He was quite boy and hadmany friends
Current Situation
He lives with his parents,
family and sister.
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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
Maturity65- death
Ego integrity vs despair Reflection on life
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Patient is the 2rdchild of 4 siblings
Psychiatry history in the family (+) Patients cousin
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Genogram
MALE FEMALE Patient
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Patient realizes that he is a male, and interests to a female.
His attitude is appropriate as a male.
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Socio-economic history
Economic scale : low
Validity
Alloanamnesis: valid
Autoanamnesis: valid
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Progression of Disorder
Symptom
Role Function
2013 May 2014Normal
Time Line
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Appearance
A male, appropriate to his age, completely clothed
State of Consciousness
Cloudly
Speech
Quantity : Decreased
Quality : Decreased
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BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
CatatoniaActive negativism
Cataplexy
Streotypy
Mannerism
AutomatismBizarre
Command automatism
Mutism
Acathysia
Tic
SomnabulismPsychomotor agitation
Compulsive
Ataxia
MimicryAggresive
Impulsive
Abulia
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ATTITUDE
Non-cooperative
Indiferrent
Apathy
Tension Dependent
Passive
InfantileDistrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibilityExcited
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Emotion
Mood
Dysphoric
Euthymic
Elevated
Euphoria
Expansive Irritable
Agitation
Cant be assesed
Affect
Inappropriate
Restrictive Blunted
Flat
Labile
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Disturbance of Perception
Hallucination
Auditory (-) Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-) Somatic (-)
Illusion
Auditory (-) Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-) Somatic (-)
Depersonalization (-) Derealization (-)
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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
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Content of Thought
Idea of Reference Preoccupation
Obsession
Phobia Delusion of Guilty
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
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Form of Thought
RealisticNon Realistic
DereisticAutism
Cannot be evaluated
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Sensorium and Cognition
Level of education : finished senior highschool
General knowledge : Good Orientation of time : Good Orientations of place : Bad Orientations of people : Good Orientations of situation : Good Working/short/long memory: cant be accessed
Writing and reading skills : cant be accessed Visuospatial : cant be accessed Abstract thinking : cant be accessed Ability to self care : cant be accessed
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Impulse control whenexamined
Self control: Enough
Patient response toexaminers question:
Bad
Insight
Impaired insight
Intellectual Insight
True Insight
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Physical State
Consciousnes : compos mentis
Vital sign :
Blood pressure : 130/80 mmHg
Pulse rate : 120 x/mnt
Temperature : 36.5 C
RR : 20 x/mnt
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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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Symptoms Mental Status Impairment
- Behaviour : Hypoactive
-Attitude: Non-Cooperative
- Mood: Dysphoric
- Affect: Blunted
- Form of Thought: Non-realistic
- Content of thought: Delution of
guilty and suspicious
-Patients response to question: bad
- Impaired insight
Daydream
Mad till
commite suicide
Unable to sleep
The patient didnt
go to work
Leasurely time is
used to daydream
only
Wont eat
Didnt socialize
with his
family/others
Male 25 years old, appropiate to his age, completely clothed
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Differential Diagnosis
F25.1 Schizoafektif Disorder Depresif Type
F32.3 Severe Depresif Episode with
Psychotic Symptom
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Multiaxial Diagnosis
Axis I : F32.3 Severe Depresif Episode withPsychotic Symptoms
Axis II : F60.1 Schizoid Personality Disorders
Axis III : Prehipertension
Axis IV : Patient felt he cant do his obligation
as a husband. Patient said his wife
having an affair with other man and
put Talak to his wife.Guilty to the Goverment
Axis V : GAF admission 20-11
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1. Problem about patients life
The patient had problem with his wife, didnt work about 3
days. Live in parents house and live with his parents.
2. Problem about patients biological stateIn depresif patient, there is abnormal balancing of the
neurotransmitter (serotonin) which has the contribution for
the depresif symptoms. We need pharmacotherapy to
rebalance the neurotransmitter
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Inpatient (hospitalization)To reduce 50% the symptoms :
Mood dysphoric
Stay alone
Feel exhausted Trouble sleeping
Feeling guilty
Decreased appetite
Commite suicide Delusion of guilty and suspicious
Response Remission Recovery
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Target therapy : 50% decrease of symptomsEmergency department
Inj Haloperidol 5 mg IM
Inj Diazepam 5 mg IV
MaintananceHaloperidol 2x5mg
Fluoxetine 1x25mg (morning)
Captopril 2x12.5mg
Plan
ECT
Re-assess patient
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Target therapy :
100% remission of symptom
Inpatient management
1. Continue the pharmacotherapy: maintenance Haloperidol
2x5mg, Fluoxetine 1x25mg (morning), Captopril 2x12.5mg
2. Improving the patient quality of life :Teach patient about his social & environment
(interact with his family, socialize with his neighbor or friends,
find a hobby to do on his spare time)
Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy
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Target therapy : 100% remission of symptom within
1 year.
- Continue the medication, control topsychiatric
- Rehabilitation : help patient to find a
hobby, help patient to interact normally with
his family, his friends and neighbor- Family education such as tell his family
about patient condition and how much
familly support affect the success oftherapy
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