Post on 07-Jul-2018
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SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ
*MORNING REPORT
Thursday afternoon, 02 January 2014
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I. PATIENT’S IDENTITY
AutoanamnesisName : Mr. HAge : 29 years oldender : Male
Address : Tegal!""u#ation : Dri$erMarital status : single%ast edu"ation : Elementary S"&oolAlloanamnesisName : Mr. 'Age : () years old*elation : &is un"le
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*Pre"ent Hi"t%ry
Poor utilization of leisure time
poor grooming
Poor utilization of leisure time
poor grooming
Easily get angry
Broke his furniture at home and hisgrand mother house
He was Wandering and could not goback home
He refused to work
Hurt himself and start to burn his
hairLaugh his own self
& 'ee( ag%
)ay %$ad!i""i%n
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• Patient has been hospitalized fourthtime in RSS !agelangPsychiatryhistory
• Hypertension "#$• Head in%ury "#$• &on'ulsion "#$• (sthma "#$• (llergy "#$
)eneralmedical history
• *rugs consumption "#$• (lcohol consumption "#$• &igarette Smoking "+$
*rugs andalcohol abusehistory and
smoking history
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*EARLY CHILDHOOD PHASE (0-3 YEARS OLD)
Psychomotoric (UNVALID DATA)
• T&ere -ere not get im#ortant data on #atients gro-t& and de$elo#ment su"& as:• rst time li/ting t&e &ead 013 mont&s4• rolling o$er 013 mont&s4• Sitting 039 mont&s4• 5ra-ling 039 mont&s4• Standing 039 mont&s4• -al6ingrunning 0972 mont&s4• &olding o8e"ts in &is &and013 mont&s4
• #utting e$eryt&ing in &is mout&013 mont&s4Psychosocial (UNVALID DATA)• T&ere -ere not get im#ortant data on -&i"& age #atient
• started smiling -&en seeing anot&ers /a"e 013 mont&s4• startled 8y noises013 mont&s4• -&en t&e #atient rst laug& or suirm -&en as6ed to #lay; nor #laying "la#s -it& ot&ers
039 mont&s4
Communication (UNVALID DATA)
• T&ere -ere not get im#ortant data on -&en patient started saying words , year like -mom.or -dad./ "0#1 months$
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Emotion (UNVALID DATA) T&ere -ere not get im#ortant data o/ #atient’s rea"tion
-&en #laying; /rig&tened 8y strangers; -&en starting tos&o- ealousy or "om#etiti$eness to-ards ot&ers and toilettraining.
Cognitive (UNVALID DATA) T&ere -ere not get im#ortant data on -&i"& age t&e
#atient "an /ollo- o8e"ts; re"ogni
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*LATE CHILDHOOD & TEENAGE PHASE
Seual !evelo"ment signs # activity (UNVALID DATA) No data on -&en #atient e=#erien"e -et dream; &air on
arm#its and #u8is; et"
* Psychomotor (UNVALID DATA)
No data i/ #atient &ad any /a$ourite &o88ies or games; i/ #atient
in$ol$ed in any 6ind o/ s#orts.* Psychosocial (UNVALID DATA)
Patient &ad ne$er 8een told /amily a8out #atient’s /riend.
* Emotional (UNVALID DATA)
not get im#ortant data on #atients rea"tion on #laying; s"ared;
s&o-ed ealously or "om#etiti$eness* Communication (UNVALID DATA)
not get im#ortant data on &o- -ell t&e relations&i# 8et-een#atient -it& #arent and &is /amily.
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*ADULTHOOD
E!ucational $istory Elementary S"&ool
%ccu"ational history Dri$er and no- not -or6
&arital Status
singleCriminal $istory
No
Social Activity Patient ha! introvert "ersonality' an! he ha! a goo! relationshi" ith his
neighour*Current Situation He li$es -it& &is /amily
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* Eri("%n*" "tage" %$ p"y+%"%+ia#dee#%p!ent
Stage -a"i+ %n$#i+t I!p%rtant Eent"
2nfancy"birth to ,3 months$
4rust 's mistrust 5eeding
Early childhood"6#7 years$
(utonomy 's shame and doubt 4oilet training
Preschool"7#8 years$
2nitiati'e 's guilt E9ploration
School age"0#,, years$
2ndustry 's inferiority School
(dolescence
",6#,3 years$
2dentity 's role confusion Social relationships
/%ung Adu#t%%d012345 year"6
Inti!a+y " i"%#ati%n Re#ati%n"ip
!iddle adulthood":;#08 years$
)enerati'ity 's stagnation Work and parenthood
!aturity"08# death$
Ego integrity 's despair Reflection on life
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*Familyi!"#$y
*Patient is t&e se"ond "&ild o/ ) si8lings.
* T&ere’s no #sy"&iatry &istory in t&e/amily.
Family i!"#$y
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*P"y+%"e7ua# Hi"t%ry
*He attra"ted a -omen 8ut &e did not dareto "on/ess.
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*G%#'$am
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Socio#economic history
• Economic scale < no data
=alidity
• (lloanamnesis < 'alid• (utoanamnesis < un'alid
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*P$#'$%!!i# # i!#$%$
Sym*"#m
R#l% +,"i#
&514&511 &51&
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Emotion
!ood
• Dys#&ori" 0@4• Ele$ated• Eu#&oria• E=#ansi$e• Irrita8le• Agitation• 5an’t 8e
assessed
(ffect
• A##ro#riate• Ina##ro#riate 0@4• *estri"ti$e• +lunted
• Blat• %a8ile
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Distur8an"e o/ #er"e#tion
Ha##u+inati%n
• (uditory "#$• =isual "#$• @lfactory "#$• )ustatory "#$
• 4actile "#$• Somatic "#$
I##u"i%n
• (uditory "#$• =isual "#$• @lfactory "#$• )ustatory "#$
• 4actile "#$• Somatic "#$
*epersonalisation "#$ *erealisation "#$
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T&oug&t #rogression
8uantity
• Logorrhea• Blocking
• Remming• !utisme• 4alk acti'e "+$
8ua#ity
• 2rrele'an answer• 2ncoherence• 5light of idea
• @'er#'alued idea• &onfabulation• Po'erty of speech• Loosening of association• Aeologisme
• &ircumtansiality• =erbigrasi• Perse'erasi• Sound association• Word salad
• Echolalia
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5ontent o/ t&oug&t
2dea of Reference
Preoccupation
@bsession
Phobia*elusion of Persecution
*elusion of Reference
*elusion of En'ious*elusion of Hipochondry
*elusion of magic#mystic "+$
*elusion of grandiose "+$
*elusion of &ontrol
*elusion of 2nfluence
*elusion of Passi'ity
*elusion of Perception
4hought of Echo
4hought of 2nsertion "+$
4hought of Broadcasting
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Borm o/ T&oug&t
*ealisti"N# R%ali!"i,Dereisti"Autisti"
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S%!#$i+m a C#'i"i#
%e$el o/ edu"ation : Senior &ig& s"&ool eneral 6no-ledge : enoug& !rientation o/ timeC#la"eC#eo#leCsituation:
goodCgoodCgoodCgood 'or6ingCs&ortClong memory : good 'riting and reading s6ills : not e=amined isuos#atial : not e=amined A8stra"t t&in6ing : not e=amined A8ility to sel/ "are : 8ad
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I!pu#"e +%ntr%# 'ene7a!ined
• Self control< enough• Patient response to
e9aminers uestion
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I"%$al S"a"+!
5on"iousnes : "om#os mentisital sign :
◦ +lood #ressure : 72?C>? mmHg
◦ Pulse rate : >? =Cmnt
◦ Tem#erature : a/e8ris
◦ ** : 2?=Cmnt
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H%a / #$m#,%*ali
Ey%! / a%mi, ,#+'"i.a --2 i,"%$i, !,l%$a --2
*+*il i!#,#$%
N%, / #$mal2 # $i'ii"y2 # *al*a4l% lym* #%!
T#$a5/
C#$ / S 126 S#+ a #$mal
L+' / .%!i,+la$ !#+2 7%%8i' --2 $#,i--
A4#m% / Pai (-) 2 #$mal *%$i!"al"i,2 "ym*ay
!#+
E5"$%mi"y / 9a$m a,$al2 ,a** $%:ll ;6<
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*N%+$#l#'i,al %5am /
*!otoric< Aormotonus> good coordination of
mo'ement
*Physiological refle9<Biceps +C+> 4riceps +C+> DPR +C+
*Pathological refle9<
Hoffman#4romer #C#> Babinski #C#>
&haddock #C#>
RES!E
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RES!E
Sy!pt%!"
Easily get angry
Laugh his own self
Broke his furniture athome and his grand
mother house
He was Wandering and
could not go back home
He refused to work
Hurt himself and start
to burn his hair
Laugh his own self
I!pair!ent
Poor utilizationof leisure time
Poor grooming
Menta#Statu"
cooperati'e2nappropiate
4hought insertion
*elution of grandious
*elution of magic
mistic
Aon Frealistic
2mpaired insight
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Dierential Diagnose
• 568/6 Schizoaffecti'e mi9ed type
• 57,/6 Bipolar affecti'e
disorder>present manic episode with
psychotic symptoms
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M+l"ia5ial Dia'#!%
(9is 2 < 568/6 Schizoaffecti'e mi9ed type
(9is 22 < R:0/3 delayed diagnosis of a9is 22
(9is 222 < Ao diagnose
(9is 2= < Psychosocial and en'ironmental problems(9is = < )(5 admission 6;#,,
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* Terapy
Hospitalization
#ur#ose o/ &os#itali
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*PLANNING MANAGEMENT
P&arma"ot&isa#y
! Emergen"y t&era#y
! In. Halo#eridol (mg 7 am#ul im
!*outine t&era#y!Halo#eridol 2 = ( mg!%itium 6ar8onat 7 = )?? mg
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P!y,#-%+,a"i#
Edu"ate t&e #atient and /amily a/ter medi"ation:
*E=#lain to #atient’s /amily a8out mentaldisorder. T&ere are many /a"tors "ause t&esym#toms..
* Treat t&e #atient a""ording to t&e /amily’sa8ility; don’t demand t&e #atient more nor less.
* Hel# t&e #atient -&en s&e needs it.
* Edu"ation o/ t&e /amily to en"ourage
"ommuni"ation and understanding.
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*PROGNOSIS
(d 'itam < ad bonam
(d functionum < dubia ad malam
(d sanationum < dubia ad malam
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Ta Y#+=