morport sabtu ay-lia
TRANSCRIPT
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Thursday, 20th September 2012
Supervisor : dr Sabar P Siregar Sp.Kj
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Sufferers Identity
Name : Mr.AAge : 25 years oldGender : MaleAddress : BanjarnegaraOccupation : Unemployed
Marriage status : SingleReligion : MuslemLast education : Junior High School
Alloanamnesis
Name : Mrs. MAge : 45 years oldRelation : Patients Mother
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Chief complaint
Anger tantrums
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Assaults neighbours
Hearing voices
controlling him Sees supernatural being
Patient felt being pushed
by non-existent person
till patient fell down.
Did not take medications
Talks to himself & laughs
by himself.
Agitated & sensitive,
short tempered
Anger tantrums (no
reason) : throwing
furniture and assaulting
family members.
Presenting illness
1 year ago
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Today
Brought to hospital today because just found
financial support
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HISTORY OF PRESENT ILLNESS
Psychiatry history
Social withdrawal since8.5 years ago.
Hallucinations,Delusions,disorientation since 8years ago.
Hospitalization 10 x inRS Banyumas.
Medications notroutinely taken
Stressor unclear
General medical history
Head injury (+) 8 yrsago
Convulsion (-)
Asthma (-)
Allergy (-)
Drugs and alcohol abusehistory and smoking
history
Alcohol consumption (-)
Tobacco consumption(+)
Drugs abuse (-)
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History of Personal Life
PRENATAL AND PERINATAL HISTORY No significant abnormality medical conditions & nutritions
during the mothers pregnancy.
No significant abnormality regarding patients birth and
birth conditions.
Patient was born at home with the help of a traditional
midwife.
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Early Childhood Phase (0-3 years old)
Psychomotoric There were no valid data on patients growth and development
such as: first time lifting the head, rolling over, sitting, crawling,
standing, walking-running, holding objects in her hand, putting
everything in her mouth, holding objects in her hand
Psychosocial
There were no valid data on which age patient started smiling
when seeing another face, startled by noises, when the patient
first laugh or squirm when asked to play, nor playing claps with
others
Communication
There were no valid data on when patient started saying words
like mom or dad, or talks.
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Emotion
There were no valid data of patients reaction 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 her mother,recognize 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 on when patients first time riding a tricycle or bicycle, if patientever involved in any kind of sports.
Psychosocial
There were no data on patients gender identification, interaction with her
surroundings
There were no data on when patient first entered primary school, how well
patient handles seperation from parents, how well she plays with new friendson first day of school
Communication
There were no valid data regarding patients ability to make friends in school,
and how many friends patient had during her schooling period.
Emotional
No valid data on patients adaptation under stress, any incidents ofbedwetting were not known.
Cognitive
No valid data on patients achievement in school, how well patient;s reading
ability and grades.
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Late Childhood & Teenage Phase Sexual development signs & activity
No valid data on when patient experience wet dream, hair on armpits andpubis, etc
Psychomotor
No valid data if patient had any favourite hobbies or games, if patient involved
in any kind of sports.
Psychosocial
Patient had many friends and did not have any known problem with friends. It is unknown if patient had any friends from the opposite gender at this page.
Emotional
No valid data if patient ever told friends or family regarding any problems.
No valid data if patient attempted to break the rules (truant schools subject,
fight with friends, bullying, etc) and consuming alcohol, smoke and drugs
Communication No valid data on how well the relationship between patient with parents and
other family.
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Family History
Patient is the eldest child of 4 siblings.
Stays with his mother and sick father at
home.
There is a history of psychiatric disorder
(type unknown) in late grandmother.
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Psychosexual history
Patient psychosexual history is appropriate of
his gender and attracted to female
Had a girlfriend but broke off 2 years ago.
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Genogram
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Economically supported by father andmother.
Socio-economic status : Low
Socio-economic
history
Alloanamnesis : valid Autoanamnesis : not validValidity
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Progression of Ilness
symptom
Role function
5 years ago8 yrs ago 1 year ago till now
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Mental State
Appearance :
Male, 25 years old, appropriate for age, satisfactory
grooming
State of Consciousness
Clouded
Speech:
Quantity: increased
Quality: poor
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Behaviour
Hypoactive
Hyperactive
Normoactive
Echopraxia
CatatoniaActive negativism
Cataplexy
Streotypy
MannerismAutomatism
Command automatismMutism
Acathysia
Tic
SomnabulismPsychomotor agitation
Compulsive
Ataxia
Mimicry
AggresiveImpulsive
Abulia
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ATTITUDE
Non-cooperative
Cooperative
Indiferrent
Apathy
Tension
Dependent
Active
Passive
Infantile
Distrust
Labile
RigidPassive negativism
Stereotypy
Catalepsy
Cerea flexibilityExcitement
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Emotion
Mood
Euthymic
Dysphoric
Euphoria
Elevated
Expansive
Irritable Cant be assesed
Affect
Appropriate
Inappropriate Restrictive
Blunted
Flat
Labile
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Disturbance of perception
Hallucination
auditory
Visual (-)
Olfactory (-)
Gustatory (-) Tactile (-)
Somatic (-)
Cannot be assessed
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-) Tactile (-)
Somatic (-)
Cannot be assessed
Derealisation (-)Depersonalisation (-)
Thi ki
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Thinking
thought progression
Quantity
Logorrhea
Blocking
Remming
Mutisme
Talk active
QualityIrrelevant answer
Coherence
Confabulation
Poverty of speech
Flight of idea
Sound association
Loosening of association
Incoherence
Word salad
NeologismeCircumstantiality
Tangentiallity
Verbigration
Perseveration
Echolalia
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Idea of Reference
Preoccupation
Obsession
Phobia
Delusion of pursue
Delusion of suspicious
Delusion of envious
Delusion of hipochondria
Delusion of magic-mistic
Delusion of control
Delusion of influence
Delusion of passivity
Delusion of perception
Delusion of grandeur
Thought of echo
Thought of insertion/withdrawalThought of broadcasting
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Thought process
Form of Thought
Realistic
Non RealisticDereistic
Autistic
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Sensorium and Cognition
Level of education : enough
General knowledge : Cannot be assessed
Orientation of time/place/people/situation:
poor/poor/poor/poorMemory : cannot be assessed
Writing & reading : cannot be assessed
Visuospatial : cannot be assessedAbstract thinking : cannot be assessed
Ability to self care : cannot be assessed
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PoorImpulse controlwhen examined
Impaired insight
Intellectual Insight
True Insight
Insight
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Internal Status
Conciousnes: compos mentis
Vital sign:
Blood pressure : 120/80 mmHg
Pulse rate : 82 x/mnt
Temperature : 36.6C
RR : 20 x/mnt
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Head: mesocephali
Eyes: anemic conjungtiva -/-, ikteric sclera -/-, pupil isocor
Neck: normal, no rigidity, no palpable lymphnode
Thorax:
Cor: S1 and S2 sound and normal
Lungs: vesicular sound, wheezing -/-, ronchi-/-
Abdomen: pain -, peristaltic normal, thympany sound
Extremity: acral temperature, cappillary refill < 2 second
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Neurological status
Motoric: normotonus, good coordination of
movement
Physiological reflex: +/+
Pathological reflex: -/-
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SIGNIFICANT FINDING RESUME Onset: 1 year ago
Stressor: Unknown
Symptoms
Anger tantrums, Agitatedand sensitive
Hearing voices, seessupernatural being
Assault neighbours
Disability
- Unemployed
- Sociallyaggressive
- Day dreamduring free
time
- Bad Selfgrooming
Mental Status
Orientation : PoorConsciousness : Clouded
Behaviour : Hyperactive,Psychomotor agitation
Attitude : Non cooperative
Mood : Irritable ; Affect : labileThought progression : logorrhea,
tangentiality
Form of thought : Autistic
Insight : Impaired
Talk and laugh by himself
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Differential Diagnose
F 20.0. Paranoid Schizophrenia
F20.2 Catatonic Schizophrenia
F 30.2 Mania with Psychotic Symptoms
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Multiaxial Diagnose
Axis I : F 20.0 Paranoid Schizophrenia
Axis II : Z03.2 No diagnosis
Axis III : None
Axis IV : unclear stressor
Axis V : GAF admission 20-11
The highest GAF in a year : 20-11
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Therapy
Hospitalization
To establish an effective association between
patients and community support systems
Hospital treatment plans should be orientedtoward practical issues of self-care, quality of life,
employment, and social relationships
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Therapy in ER
Inj. Haloperidol 5 mg IM
Inj. Diazepam 5 mg IV
Therapy in Ward
Haloperidol tab 2 x 5 mg
Suggestion for ECT if there is not relative
contraindication Psychosocial Therapy
Family oriented therapy
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PROGNOSIS
Ad vitam : dubia ad bonam
Ad functionum : dubia ad malam
Ad sanationum : dubia ad malam
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Thank you