morpot umy-unisula (2)
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Transcript of morpot umy-unisula (2)
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Click to edit Master subtitle style5/20/12
Morning reportTuesday, 08-05-2012
Supervisor : dr. Sabar P. Siregar,Sp.Kj
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Patient identity
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Alloanamnesis
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Chief complaint
Patient talked alone + 3months before admission
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History of PresentIllness
1 week
before
admission
3 months
before
admission
Patient talked to him selfEasily irritatedLoss of appetiteSleeping disturbanceLike being alonePatient thought that he saw a shadow, and hearthat someone called him.
Patient felt that someone chasing himDisturbing his friend
Patient talked to him selfLoss of appetiteSleep disturbance (initial insomnia)Liked being alonePatient thought that his friend would liketo do harmEasily irritatedPatient thought that he saw a shadow,
and hear that someone called him
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Previous History of Disease
MEDICALHISTORY
DRUGSHISTORY
PSYCHIATRYHISTORY
Havent been hospitalizedbefore
DM(-) Hypertension(-)Asthma(-)Alergy (-) Seizure history (-)
Drugs History (-)Alchoholic (-)Smoking (-)
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History of personal life
Prenataland
PerinatalHistory
No Data
Early
ChildhoodPhase
No Data
Intermediate
ChildhoodPhase
Patient finished elementaryschool at 12 y.o, but havent
passed the examination.Late
ChildhoodPhase
Patient entered Junior HighSchool at 14 y.o after gettingPaket B.
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AdulthoodPhase
Education : Junior High SchoolOccupation : UnemployedReligion : praying frequently, 5
times/dayMilitary : No dataPsikosexual : Patient performand behave like a man,attracted to women.
Frequentlymasturbated, twice a dayCriminal : No data
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Genogram
Patient
NormalWoman
NormalMan
Suicide
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Family History :Patient is the third child from 6 siblings.His younger brother was suicide. His
father is unemployed, and always prayall day long.
Sosioeconomic History :
Patient is unemployedPatients mother is the main support ofhis family economic lifeSocial interaction is limited
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Level of convidence
Alloanamnesis : untrustable
Autoanamnesis : trusted
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Illness progression
symptom
Role
function
3monthsbeforeadmissi
on
1 weekbeforeadmissi
on
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A. GENERAL DESCRIPTION
1.
APPEARANCEA man, looked like his age
He wore a black trousers with white shirt
He has black hair and his body postureis astenicus
2. Psychiatry Conciousness
Mental State
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3. behavior
normoactive
Hypoactive
Hyperactive
Echoplaxia
Catatonia
Active negativisme
Catoplexi
Streotype
Mannerism
Otomatism
q Command otomatismq Acathysiaq Ticq Sonambulismq Psychomotor
agitationq Compulsiveq Ataxiaq Mimicryq Aggresiveq Impulsiveq Abulia
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4. attitude
CooperativeNon-cooperative
Indiferrent ApathyTention Dependent Active
Passive
Infantile Distrust Labil
Rigid Passive negativism Streotype Catalepsi Cerea flexibility
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5. Psychis contact
easily drawn, easyto be specified
hardly drawn, easy to bespecified
hard drawn, hard to bespecified
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B. EMOTION
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C. PERCEPTION DISORDER
Depersonalitation :
-
Dereliasitation: -
Halucination
AuditoryVisualOlfactoryGustatoryTactileSomatic
Illusion
AuditoriyVisualOlfactoryGustatory
Tactile
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D. Thought process
1. Thought progression
QUANTITY Logorrea
Remming Blocking Mutisme Talkactive
QUALITY
coherenceIncoherence
Flight of idea Circumstansiality Poverty of speech
neologismTangensiality Verbigrasi Perseverasi Convabulation Ecolali
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2. Thought content
Idea of reference Preoccupation Obsession Phobia Delusion of suspicious Delusion of envious
Delusion of
persecutory Grandious Delusion
Delusion ofmagic-mistic
Delusion of control Delusion of influence Delusion of passivity Delusion of perceptionThought of echo
Thought ofinsertion/withdrawal
Thought of broadcasting
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4. Sensorium & cognition
Educational : lack of educational
Knowledge : good
Orientation w/t/o/s :good/good/good/good
immediate memory/short/long :good/good/good/good
ability to read and write : good
Visuospatial ability : cant be evaluated
Abstract thought : can`t be evaluated
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Si ifi Fi di
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Significant FindingResume
A man, 22 years old, unemployed
Talk to himself
Like being alone, got sleep disturbance(initial insomnia), loss of appetite,easily irritated.
Attitude : cooperative, behavior :normoactive
Mood : dysforic, Affec : appropiate,restrictive
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Deterioration :
role function : poor Social function : poor
Sparetime managemet : poor
self care : enough
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Differential Diagnosis
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Multiaxial diagnosis
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Hospitalized
- Explain to his family about the mental disorder ofthis patient include the causes.
- Describes steps of treatment-family must maintain the patients drugs consumptionand routine doctor consultation , so it will increase theefficacy of treatment-familiy must keep in touch with patient intensively, sothe patient will not feel lonely- the family shouldnt force the patient to think like a
Farmacotherapy : Haloperidol tab 2x5 mg/day
Family education:
TREATMENT
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Prognosis
Ad vitam : dubia ad malam
Ad Sanationum : dubia ad malam
Ad Fungsionum : dubia ad malam
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