skizofrenia manik

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SUPERVISOR dr. Sabar P. Siregar MORNING REPORT Sunday morning shift, 31 th August 2014

Transcript of skizofrenia manik

MORNING REPORT

SUPERVISOR dr. Sabar P. Siregar, Sp.KJMORNING REPORTSunday morning shift, 31th August 20141Patient IdentityName : Mr. ASSex: MaleAge : 22 years oldAddress : WonosoboOccupation : UnemployedMarital State : Unmarried

RELATIVES IDENTITYName: Mrs. ISex: FemaleAge: 52 years oldRelation: MotherName: Mrs. PSex: FemaleAge: 45 years oldRelation: AuntReason patient was brought to emergency roomPatient was quite talking, muting, didnt want to communicateStressorHe was forbidden to attend the marriage of his cousinPresent HistoryQuietmutingTalk and laugh by himself

He can not do daily activities normally, for example: eating, bathing, tidy upPoor utilization of leisure time (sleep)Couldnt socialize with others2 months agoPSYCHIATRIC HISTORY In 2010, patient had aggressive symptoms such as uncontrolled anger, destructive acting and irritable mood. Patient was being in ward for a month. In 2012, patient had same symptoms like before. Patient was often to pee in the bed. Patient was being in ward for 3 months. Day of Admission31th August 2014Patient was brought because of: Quiet Muting Talk and laugh by himself

Brought to hospital by his mother and aunt

He cant do his daily activities normallyPoor utilization of leisure time (sleep)He couldnt socialize with other peopleThe patient had never seek for a help from a doctor before for this present illnessEARLY CHILDHOOD PHASE (0-3 YEARS OLD)Psychomotoric (Suspect Developmental Delay) - According to his mother, patients growth and development was normal like: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) 20 monthsholding objects in her hand(3-6 months)putting everything in her mouth(3-6 months)

Psychosocial (No Valid Data)- 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)

Communication (NO VALID DATA) - There were no valid data on when patient started bubbling. (6-9 months)

Emotion (NO VALID DATA)- 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 (NO VALID DATA) - 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.11INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)Psychomotor (NO VALID DATA) No valid data on when patients first time playing hide and seek or if patient ever involved in any kind of sports.Psychosocial Patient was known as an obedient boy, and never be a burden to his parentCommunicationPatient was introvert and couldnt make many friends.Emotional (NO VALID DATA)No valid data on patients emotional.CognitivePatient didnt pass first grade in elementary school, after that patient didnt continue his formal education. There was no informal education also.12LATE CHILDHOOD & TEENAGE PHASESexual development signs & activity No data on when patient first experience of wet dreams. According to his mother, patient had ever mentioned that he liked a woman.

PsychomotorPatient favourite hobbies is singing and can play guitar. He cant write and read.

PsychosocialPatients started growing up introvert and not much talking

EmotionalHe was very close to his mother, and looked like a dependent boy.

CommunicationPatient has just few friends, uncommunicative, and not much going out.13ADULTHOOD Educational HistoryHe didnt pass first grade in elementary school because he wasnt able to catch up the lesson

Occupational historyHe helped his mother for feeding chickens.

Marital StatusUnmarried

Criminal History No criminal hsitory

Social Activity Before he was sick, he already had few friends and difficult to make new friendsHe never joined any social event.

Current SituationHe lives with his father and older brother. His mother worked in Jakarta. Everyday he like to visit his aunt house and sometime acts childish to his aunt as mother.14Eriksons 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 lifePatient is the 2nd child of 4 siblings

There is psychiatry disorder in family history, known as his uncle.

FAMILY HISTORY16GenogramFemaleMaleDeadPatientMental disorderLive in one housePSYCHOSEXUAL HISTORYPatient realizes that he is male, and has interests to female. His attitude is appropriate as a male.18Progression of DisorderSymptomRole Function2010Now 2012Mental State 31th August 2014BEHAVIOUR HypoactiveHyperactiveEchopraxiaCatatoniaActive negativismCataplexyStreotypyMannerismAutomatismBizarreCommand automatismMutismAcathysiaTicSomnabulismPsychomotor agitationCompulsiveAtaxiaMimicryAggresiveImpulsiveAbulia -echopraxia : pengulangan gerakan yang sama oleh pasien meniru gerakan pemeriksa-catatonia : perilaku catatone, mempertahankan gerakan aneh-active negativisme : tahanan tanpa motivasi untuk menggerakkan (memberontak, melawan gerakan)-cataplexy : penurunan tonus otot karena konflik psikologis-stereotypy : pergerakan/pembicaraan yang terfiksasi dan berulang-ulang-mannerism : pengulangan gerakan yg tidak disadari dan menjadi kebiasaan-automatism : tindakan yang otomatis/spontan, biasanya mewakili aktivitas simbolik yang tidak disadari-bizarre : aneh -command automatism : melakukan apa yg diperintahkan secara otomatis-mutism : pasien tidak mau bicara-impulsive : dari keadaan diam lalu tiba2 melakukan sesuatu yg dia ingin dan langsung dilakukan22ATTITUDEIndiferrentApathyTensionDependentPassiveInfantileDistrustLabileRigidPassive negativismCatalepsyCerea flexibilityExcited-excited: agitated, purposeless motor activity without external stimuli23EmotionDisturbance of PerceptionDepersonalization (-)Derealization (-)Thought ProgressionContent of ThoughtCan not be assessedIdea of ReferenceIdea of GuiltPreoccupationObsessionPhobia 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 Insertion & withdrawalThought of BroadcastingForm of ThoughtNon RealisticDereisticAutisticCannot be evaluated

28Sensorium and CognitionLevel of education: Cant be assessedGeneral knowledge: Cant be assessedOrientation of time : Cant be assessedOrientations of place: Cant be assessedOrientations of people: Cant be assessedOrientations of situation: Cant be assessedWorking/short/long memory: Cant be assessedWriting and reading skills: Cant be assessedVisuospatial: cant be accessedAbstract thinking: cant be accessedAbility to self care: Poor

Physical StateConsciousnes : compos mentisVital sign :Blood pressure: 125/80 mmHgPulse rate : 98x/mntTemperature : AfebrileRR: 16 x/mntReview SystemHead : normocephali, mouth deviation (-)Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocoreNeck : normal, no rigidity, no palpable lymph nodesThorax :Cor : S 1,2 regularLung : vesicular sound, wheezing -/-, ronchi-/-Abdomen : Pain (-) , normal peristaltic, tympany sound Extremity : Warm acral, capp refill