Morpot Nida

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MORNING REPORT Supervisor: dr. Sabar P. Siregar, Sp. KJ. Friday, 20th March 2015

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Transcript of Morpot Nida

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MORNING REPORTSupervisor:dr. Sabar P. Siregar, Sp. KJ.

Friday, 20th March 2015 Patients IdentityAutoanamnesisName: Mrs. SAge: 51 years oldGender: FemaleAddress: WonosoboOccupation: HousewifeMarital status: MarriedLast education: Elementary School (graduated)

Alloanamnesis

Name: Mr. AAge:19 years oldAddress: WonosoboRelation: Patients SonThe reason patient was brought to the hospitalThe patient always crying hysterically without reason since one day agoSTRESSORPatient always get scolded by her husband because little problem (Her husband has bad temperament but since he threatened fired from his job, he becomes more irritable).

Januari 2015 (2 Month Ago)Patient always get scolded by her husband because little problem (Her husband has bad temperament but since he threatened fire from his job he becomes more irritable).Patient feels afraid every time when she look at her husband at home.She always looks depressed and daydreaming.Her activity as housewife was decrease.

February 2015 (one month before admission)Patient began feel her body blew by someone when she alone, she didnt look any person who blow her body, she feels it in conscious and it always happen repeatedly, after that she feel her body was hot and her stomach was pain. She went to doctor to examine her body, but the doctor said there is no problem with her body. She went to other doctor but the symptoms didnt get better.She can do anything if she feel her body was hot, such as rolling in floor, pound on wall, scream, crying ,or angry to her children.She cant sleep because she often feels afraid when she went to sleep, she looks people bring bier to her, she think that she will die soon.She still bath and eat by him self but she lose appetite.She cant do anything as housewife totally because she feels afraid everyday.

20th March 2015 (the day of admission)Patient was brought by his family to Prof dr. Soerojo Magelang Asylum, because :Patient was crying hysterically without any reason and didnt sleep at night because she was afraid.

9Family HistoryThere is no history of psychiatric illness in his family. Progression of IllnessSymptomsRole FunctionJanuary2015March 2015GENOGRAMEARLY CHILDHOOD PHASE (0-3 YEARS OLD)Psychomotoric (No Data) 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 (No Data) There are patiens psychosocial such as: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)Communication (No Data) Patient started saying bubling word (6-9 months).

Emotion (No Data)Patient had reaction when playing, frightened by strangers, when starting to show jealousy or competitiveness towards other and toilet training.

Cognitive (No Data) The patient can follow objects, recognizing her mother, recognize her family members.The patient first copied sounds that were heard, or understanding simple orders.14INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)Psychomotor (No Data) Patients first time riding a tricycle or bicycle, if patient ever involved in any kind of sports.Psychosocial (No Data) Patient interaction with patients surrounding, no valid data on when patient first entered primary school, on how well patient handle seperation from parents, how well he play with his new friend on first day school.Communication (No Data) Patient ability to make friends at school and how many friends patient has during his school period.Emotional (No Data)Patients adaptation under stress, any incidents of bedwetting were not known.CognitivePatients study from primary school on 6th years old until junior high school. Patient got bad grade at grade 4th and need to repeat his grade.15LATE CHILDHOOD & TEENAGE PHASESexual development signs & activity (No Data) No data on when patient experience Wet Dream, hair on armpits and pubis, etcPsychomotor (No Data) No data about patient hobbies.Psychosocial (No Data) No valid dataEmotional (No Data) No valid data on patients reaction on playing, scared, showed jealously or competitivenessCommunication (No Data) The relationship between patient with parents and other family is goodPsychomotor : jangan lupa diganti karena yang dibuat PPT ini sesuai pasien Ms. Af16Eriksons stages of psychosocial developmentStageBasic ConflictImportant EventsInfancy(birth to 18 months)Trust vs mistrustFeeding Early childhood(2-3 years)Autonomy vs shame and doubtToilet trainingPreschool(3-5 years)Initiative vs guiltExplorationSchool age(6-11 years)Industry vs inferioritySchoolAdolescence(12-18 years)Identity vs role confusionSocial relationshipsYoung Adulthood(19-40 years)Intimacy vs isolationRelationshipMiddle adulthood(40-65 years)Generativity vs stagnationWork and parenthoodMaturity(65- death)Ego integrity vs despairReflection on lifeMental State(Friday, 20th March 2015)EmotionDisturbance in PerceptionProgression of ThoughtContent of thoughtIdea of ReferencePreoccupationObsessionPhobia Delusion of PersecutionDelusion of ReferenceDelusion of EnviousDelusion of HipochondryDelusion of magic-mysticDelusion of grandioseDelusion of ControlDelusion of InfluenceDelusion of PassivityDelusion of PerceptionDelusion of SuspiciousThought of EchoThought of InsertionThought of BroadcastingThought formNon RealisticDereisticAutistic

Sensorium and CognitionLevel of education: AppropriateGeneral knowledge: No DataOrientation of time/place/people/situation: good/bad/good/goodWorking/short/long memory: goodWriting and reading skills: not checkedVisuospatial: not checkedAbstract thinking: not checkedAbility to self care: good

26Internal StatusConciousnes neurology : compos mentisVital sign :Blood pressure: 130/70 mmHgPulse rate : 80 x/mntTemperature : 36,5 CRR: 24 x/mntVital sign pake tensi manual yaa27Head : normocephaliEyes : anemic conjungtiva -/-, icteric sclera -/-, pupil isocoreNeck : normal, no rigidity, no palpable lymph nodesThorax:Cor : S 1,2 Sound and normalLung : vesicular sound, wheezing -/-, ronchi-/-Abdomen : Pain (-) , normal peristaltic, tympany sound ,tenderness pain (-)Extremity : Warm acralNeurological exam : not examinedSymptom: Mental Status:

Impairment:

Hysterical crying Sleeping difficulty (hard to sleep)Delusion of magic mystic, she looks people around him bring bier to pick up her die.She feel her body blew by someone when she alone, she didnt look any person who blow her body, she feels it in conscious and it always happen repeatedly, after that she feel her body was hot and her stomach was pain. Decreased concentrationShe cant do anything as housewife totally because she often afraid everyday

Behavior: HipoactiveAtitude : cooperatifMood : DisforikAffect : Appropriate, restrictive, labilProgression of Thought: Remming, coheren.Content of thought : Delusion of magic mysticForm of thought : non-realisticPerception : Hallucination Visual and taktilInsight: Intellectual insightPatient decreased socializationPatient cant work as housewife because his concentration is decreased and often afraid.

A woman, 51 years old, married, housewife, change in behavior: hysterical crying without reason, didnt sleep at night because she was afraid, she cant do anything as housewife totally because she often afraid everyday29SyndromeSchizophrenia SyndromeDepressive SyndromeDelusion of Magic MysticVisual HallucinationTaktil HallucinationNon-RealistikIntellectual InsightDisforik, Remming, decrease of activity, look sad and daydreaming, cant sleep. Differential DiagnoseF 25.1 Skizoafektif disorder depressive typeF 32.3 Severe depressive episode with Psychotic Syndrome

Multiaxial DiagnoseAxis I: F32.3 Severe depressive episode with Psychotic SyndromeAxis II: R46.8 Delayed diagnoseAxis III: No diagnoseAxis IV: Problems related with her husbandAxis V: GAF 40-31PLANNING MANAGEMENT Hospitalization Pharmacotherapy Psycho-educationPLANNING MANAGEMENTHospitalizationThe purpose of hospitalization is to decrease the symptoms, so patient can handle patients selfHospital treatment plans should be oriented toward practical issues of quality of life, role function and social relationships.To establish an effective association between patients and community support systems.

PLANNING MANAGEMENTPharmacotherapyIGD:Haloperidol 10 mg IMDiazepam 10 mg IVBangsal: Fluoxetin 2x 20mgHaloperidol PO2 x 5 mgTrihexiphenidyl 2 x 2 mgDiazepam 1x 5 mg

35PLANNING MANAGEMENTPsycho-educationEducate the patient and family :Education of the family to encourage communication and understanding.Help the patient when patient needs it. Treat the patient according to the patients ability, dont demand the patient more nor less.Thank You