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MORNING REPORTSATURDAY, June 14th2014
SUPERVISORdr. Sabar P. Siregar, Sp.KJ
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Patient Identity
Autoanamnesis
Name : Mr. A
Sex : Male
Age : 22 years old
Address : Kebumen
Occupation : Labor
Marital State : Single
Alloanamnesis
Name : Mr. S
Sex : Male Relation : His father
Age : 52 years old
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Stressor
HIS MOTHERS DEATH
FALSE BELIEF
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PAT I E N T C O N F U S E , T R Y T O S U I C I D E , A N D
I RRI TAB I L I TY.
Reason patient was brought
to emergency room
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Present History
3 WEEKS AGO:QUIET
TRY TO SUICIDE
IRRITABILITY
RAMPAGE
TALK TO HIMSELF
TALK LESS
SLEEP DISTURBANCE
CANT SOCIALIZE WITH
OTHERS
INCREASE APPETITE
FEBRUARY 2014 : CONFUSE
QUIET
IRRITABILITY
CANT SOCIALIZE WITH
OTHERS
JANUARY 2014
FEEL GUILTY
CANT SOCIALIZE WITH
OTHERSBrought to
hospital
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Day of AdmissionJune, 14ths 2014
Patient was brought with the
complaints of:
QUIET
TRY TO SUICIDE
IRRITABILITY RAMPAGE
TALK TO HIMSELF
TALK LESS
SLEEP DISTURBANCE
Brought to hospital byHis father
CANT SOCIALIZE WITH OTHERS
INCREASE APPETITE
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Psychiatric History
Patient has no psychiatric problems
history before
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Head injury (-)
Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)
Generalmedical
history
Drugs consumption (-)
Alcohol consumption (+)
Cigarette Smoking (+)
Drugs and
alcohol abusehistory and
smoking history
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EARLY CHILDHOOD PHASE (0-3 YEARS OLD)
Psychomotoric There were no valid data on patientsgrowth 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 hermouth(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 withothers (6-9 months)
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Communication
There were no valid data on when patient started bubbling. (6-9months)
Emotion
There were no valid data of patients reaction when playing,frightened by strangers, when starting to show jealousy orcompetitiveness towards other and toilet training.
Cognitive
There were no valid data on which age the patient can followobjects, recognizing her mother, recognize her family members.
There were no valid data on when the patient first copied soundsthat 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 playing hide and seek or if
patient 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 howmany friends patient have during her school period
Emotional
No valid data on patients emotional.
Cognitive
No valid data on patients cognitive.
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LATE CHILDHOOD & TEENAGE PHASE
Sexual development signs & activity (NO VALID DATA) No data on when patient first experience of wetdream, etc.
Psychomotor (NO VALID DATA)
No data if patient had any favourite hobbies or games, if patient involved
in any kind of sports. Psychosocial (NO VALID DATA)
No valid data regarding patient psychosocial.
Emotional (NO VALID DATA)
No valid data on patients emotional.
Communication (NO VALID DATA)
No valid data regarding patient ability to make friends at school and howmany friends patient have during his high school period
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ADULTHOOD
Educational History
He finished Junior High School
Occupational History
Hes worked
as a Labor. After 6month ago he is unworked.
Marital Status
Single
Criminal History No
Social Activity
He was friendly
Current Situation
He lives with his father andbrother. His father is a farmer
and his brother is jobless.
His Mother was died
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Eriksons stages
of psychosocial development
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
Maturity
(65- death)
Ego integrity vs despair Reflection on life
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FAMILY HISTORY
Patient is the 2ndchild of 2 siblings
There is no psychiatry history in the family
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Male Female Patient Lives together
GENOGRAM
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PSYCHOSEXUAL HISTORY
Patient realizes that he is a male, andinterested in woman. 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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Symptom
Role Function
January
2014
February
2014
Progression of Disorder
3 Weeks
Ago
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Mental State June 14 th2014
Appearance
A male, appropriate to his age, completely clothed
State of Consciousness
Cloudy
Speech Quantity : decrease
Quality : decrease
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BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
CatatoniaActive negativism
Cataplexy
Streotypy
Mannerism
AutomatismBizarre
Command automatism
Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
MimicryAggresive
Impulsive
Abulia
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ATTITUDE
Non-cooperative
Indiferrent
Apathy
Tension Dependent
Passive
Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibilityExcited
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Emotion
Mood
Dysphoric Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
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 Idea of Guilt
Preoccupation
Obsession
Phobia
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 junior high school
General knowledge : Cant be assessed
Orientation of time : good
Orientations of place : bad Orientations of people : good
Orientations of situation : bad
Working/short/long memory: good
Writing and reading skills : Cant be assessed Visuospatial : Cant be assessed
Abstract thinking : good
Ability to self care : good
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Impulse control whenexamined
Self control: good
Patient response toexaminers question:
good
Insight
Impaired insight
Intellectual Insight
True Insight
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Physical State
Consciousnes : clear consciousness
Vital sign :
Blood pressure : 130/80 mmHg
Pulse rate : 80 x/mnt
Temperature : 36.5 C
RR : 20 x/mnt
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Review System
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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Mental Status Impairment
- Behavior:hipoactive, Attitude:
cooperative
- Mood : dysphoric
-Affect : appropiate, stabile
-Disturbance of Perception:
hallucination visual (+) and
auditory (+)
-Thought of Progression:
Quantity: talk active
Quality: circumtansiality
-Content of Thought : idea of guilt,
delution of persecution
-Form of thought : non-realistic
QUIET
TRY TO SUICIDE
IRRITABILITY
RAMPAGE
TALK TO HIMSELF
TALK LESS
SLEEP
DISTURBANCE
CANT SOCIALIZE
WITH OTHERS
INCREASE APPETITE
Symptoms
Patient is a male, 22 years old, confuse, try to suicide and irritability.
RESUME - Day of admission
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F32.3 Severe Depression With Psychotic
Symptom
F25.1 Schizoaffective Type Depression
Differential Diagnosis
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Axis I : F32.3 Severe Depression With Psychotic
Symptom
F25.1 Schizoaffective Type Depression
Axis II : Z03.2 No Diagnose
Axis III : no diagnose
Axis IV : his mothers death, false belief
Axis V : GAF admission 20-11
Multiaxial Diagnosis
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PROBLEM RELATED TO THE PATIENT
1. Problem about patients life
His mothers death
False belief
2. Problem about patients biological state
There were abnormality imbalance neurotransmitter, increase of
serotonin, dopamine. So the patient needs psychopharmacology
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PLANNING MANAGEMENT
INPATIENT (HOSPITALIZATION)
To reduce 50% the symptoms :
QUIET
TRY TO SUICIDE
IRRITABILITY
RAMPAGE
TALK TO HIMSELF
TALK LESS
SLEEP DISTURBANCE
Response Remission Recovery
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RESPONSE PHASE
Target therapy :50% decrease of symptoms
Emergency departmentInj. Diazepam 10 mg IV
Inj. Haloperidol 5 mg IM Maintenance
Haloperidol 2x5 mg
Amitriptilin 3x25 mg
PlanningECT
Re-assess patient
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REMISSION PHASE
Target therapy : 100% remission of symptom
Inpatient management Continue the pharmacotherapy: haloperidol tab 2x5 mg, amitriptilin 3x25
mg Improving the patient quality of life :
Teach patient about her social & environment (interact with his family,socialize with her neighbor or friends, find a hobby to do on her spare time,and find a job that fits him well.)
Outpatient management Pharmacotherapy
Psychosocial therapy
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RECOVERY PHASE
Continue the medication, control to psychiatric
Rehabilitation :- Help patient to interact normally with his
family, friends, and neighbor
- Family education
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Thank you