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7/24/2019 Morning Report 15 Sept Jiwa
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SUPERVISORSUPERVISOR
dr. Sabar P. Siregardr. Sabar P. Siregar,,
MORNINGMORNING
REPORTREPORT
Monday night shift 15thSeptember2014
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Patient Identity
Name : Ms. Su
Sex : Female
ge : !" years old
ddress : #emanggung
$%%upation : &nemployed ' used to bebabysister(
Marital Status : Single
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RELATIVES IDENTIT
Name : Mr. ) Sex : Male
ge : *1 years old
+elation : Father
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Rea!"n patient #a! br"$g%t t"
e&ergen'y r""&
,atient -as taling to herself/laughing alone/ getting angry easily
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Pre!ent (i!t"ry
n ugust/patient uit her
ob as maid and
returned fromSemarang
be%ause she -as
feelingunsatis3ed -ith
her ob
1 month
ago'2014(
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4 daysago
'2014( ,atient ased for
permission to -or in big%ity but not allo-ed byher parents. hendenied by her parents/she started to get angryeasily.
Impairment :
Patient could not sleep and unable to
communicate well with others
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2 daysago
'2014( ,atient started to tal and
laugh by herself. tnight/ patient %ould notsleep and startedsinging. ,atient -as tiedbe%ause she tried toleae home.
Impairment :Patient could not sleep and unable to
communicate well with others
Patient could not take care of herself
(refused to bathe and poor appetite)
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Stressor
Patient was denied by herparents to work in big city.
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Day ") Ad&i!!i"n15thSeptember
2014
6rought to thehospital
be%ausepatient taledand laughed
by herself
6roughtto the
hospital by herfather'in tied
%ondition(
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PS*(IATRI* (ISTOR
Sin%e 1771 patient -as admittedin +S8 for 5 times for same
reason
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EARL *(ILD(OOD P(ASE + EARSEARL *(ILD(OOD P(ASE + EARS
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EARL *(ILD(OOD P(ASE +- EARSEARL *(ILD(OOD P(ASE +- EARS
OLD/OLD/
Psychomotoric9 #here -ere n" 0a1id data on patients gro-th and deelopment be%ause
her father 3rst time lifting the head '!9* months( rolling oer '!9* months( Sitting '*97 months( ra-ling '*97 months(
Standing '*97 months( -aling9running '7912 months( holding obe%ts in her hand'!9* months( putting eerything in her mouth'!9* months(
Psychosocial
9 #here -ere n" 0a1id data on patients gro-th and deelopment be%auseher father started smiling -hen seeing another fa%e '!9* months( startled by noises'!9* months( -hen the patient 3rst laugh or suirm -hen ased to play/ nor playing
%laps -ith others '*97 months(
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Communication- #here -ere no alid data on -hen patient started bubbling
be%ause her father %ouldn;t remember. '*97 months(
Emotion-#here -ere no alid data on patients rea%tion -hen playing/frightened by strangers/ -hen starting to sho- ealousy or
%ompetitieness to-ards other and toilet training be%auseher father %ouldn;t remember
Cognitive#here -ere no alid data be%ause her father %ouldn;tremember/ su%h as:
9 -hi%h age the patient %an follo- obe%ts/ re%ogni
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INTERMEDIATE *(ILD(OOD +-22 EARSINTERMEDIATE *(ILD(OOD +-22 EARS
OLD/OLD/Psychomotor
No alid data on -hen patient;s 3rst time playing hide andsee/ but patient -as inoled in %ertain ind of sports.
Psychosocial
She ne0er in0"10ed in a 3g%t -ith other ids.
CommunicationShe %a! )e# )riend! at !'%""1during %hildhood.
Emotional
She -as a 4$iet 5id.
CognitiveShe -as an a0erage and di1igent !t$dent.
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LATE *(ILD(OOD 6 TEENAGELATE *(ILD(OOD 6 TEENAGE
P(ASEP(ASESexual development signs & activity
No data on -hen patient get her menar%he. She is attra%ted toopposite sex.
PsychomotorShe often inoled in household %horus lie %ooing
Psychosocial
She dropped out after elementary s%hool and started -oring as ababysister
Emotional
She -as a uite girl.
Communication
,atients has a fe- friends
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ADULT(OOD
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Eriksons stages of psychosocial
development
Stage Basic onflict Important !"entsInfancy(birth to #$ months)
%rust "s mistrust &eeding
!arly childhood(' years)
*utonomy "s shame and doubt %oilet training
Preschool(+ years) Initiati"e "s guilt !,ploration
School age(6-11 years)
Industry vs inferiority School
Adolescence(12-18 years)
Identity vs role confusion Social relationships
Young Adulthood(19-! years)
Inti"acy vs isolation #elationship
-iddle adulthood(/0+ years)
1enerati"ity "s stagnation 2ork and parenthood
-aturity(0+ death) !go integrity "s despair 3eflection on life
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7AMIL (ISTOR
,atient is the 2nd%hild among !siblings
,sy%hiatry history in the family'9(
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Gen"gra&
M=> F>M=> ,#>N# =?>#$@>#A>+
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PS*(OSE8UAL(ISTOR
Patient reali4es that she is female5 and has interests to
male. 6er attitude is appropriate as a female.
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Progression of Disorder
Symptom
+ole Fun%tion
No-Mar%h2014
1771
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Menta1 State
29t%
Septe&ber :2;
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%hopraxia
atatonia%tie negatiismataplexyStreotypyMannerism
utomatism
ommandautomatismMutism%athysia
#i%Somnabulism,sy%homotor agitationompulsie
taxiaMimi%ryAggre!!i0eI&p$1!i0ebulia
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ATTITUDE
ndiferrent pathy
#ension Bependent ,assie Non
%ooperatie
nfantileBistrustLabile,assie negatiismatalepsyerea CexibilityE='ited
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E&"ti"n
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Di!t$rban'e ") Per'epti"n
7epersonali4ation () 7ereali4ation ()
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T%"$g%t Pr"gre!!i"n
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*"ntent ") T%"$g%t an not be assessed
Idea of 3eference
Idea of 1uilt
Preoccupation
$%session
Phobia
7elusion of Persecution
7elusion of 3eference
7elusion of !n"ious
7elusion of 6ipochondry
7elusion of magicmystic
&elusion of grandiose
7elusion of ontrol
7elusion of Influence
7elusion of Passi"ity
7elusion of Perception
7elusion of Suspicious
%hought of !cho
%hought of Insertion 8
withdrawal
%hought of Broadcasting
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7"r& ") T%"$g%t
Non RealisticBereisti%
utismannot be ealuated
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Sen!"ri$& and *"gniti"n
=eel of edu%ation : >lementary s%hool @eneral no-ledge : %an;t be assessed $rientation of time : bad
$rientations of pla%e : good $rientations of people : good $rientations of situation : bad oringDshortDlong memory: good
riting and reading sills : good ?isuospatial : %an;t be a%%essed bstra%t thining : %an;t be a%%essed bility to self %are : poor
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P%y!i'a1 State
ons%iousnes : %ompos mentis?ital sign :
6lood pressure : 11!DE" mmAg
,ulse rate : 72 xDmnt#emperature : febris
++ : 24 xDmnt
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Review System
Aead : normo%ephali/ mouth deiation '9(
>yes : anemi% %onungtia '9(/ i%teri% s%lera '9(/ pupil
iso%ore
Ne% : normal/ no rigidity/ no palpable lymph nodes
#horax :
or : S 1/2 regular
=ung : esi%ular sound/ -hee
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3!S9-! female/ !" years old/ appropriate
a%%ording to her age
+eason to be brought to hospital : ,atienttaled/ laughed by herself/ and easy to getangry
She has been singing loudly at night/diH%ulty in falling asleep/ loss of appetite/poor self9%are
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Menta1Stat$! I&pair&ent
96ehaior: hypera%tie/aggressie/ impulsie9ttitude: ex%ited9Ie%t: inappropriate/eleated9Mood : irritable9#hought progression:
9 Juantity : logorrhea9 Juality : loosening
of asso%iation/irreleant ans-er
9Form of thought: nonrealisti%9ontent of thought :
delusion of grandiose9,atient;s response to
#aling and
laughing byherself
Singingloudly atnight
@etting
angry easily
She %ouldn;tsleep
She %ouldn;t%ommuni%ate-ell -ithothers
,oor self9%are
=oss ofappetite
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BiIerential Biagnosis
F 25.0 S%hipisode -ith ,sy%hoti%>pisode
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M$1tia=ia1 Diagn"!i!
xis : F 25.0 S%hi
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,roblem related to the patient
9 ,atient left her ob be%ause she -as not satis3ed-ith the ob9 ,atient;s parent not allo-ing her to -orin big %ity
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PLANNINGPLANNING
MANAGEMENTMANAGEMENTInpatient +%"!pita1i>ati"n/
ggressie
,oor self9%are=ogorrhea
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RESPONSE P(ASERESPONSE P(ASE
Target t%erapy ? 50L de%rease of symptoms
E&ergen'y depart&entAaloperidol 5mg i.mBia
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REMISSION P(ASEREMISSION P(ASETarget t%erapy ?2@ re&i!!i"n ") !y&pt"&
Inpatient &anage&entontinue the pharma%otherapy: maintenan%eAaloperidol 2 x 5 mg
1.mproing the patient uality of life :#ea%h patient about his so%ial enironment'intera%t -ith her parents/ so%iali
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RE*OVER P(ASERE*OVER P(ASE- *"ntin$e t%e &edi'ati"n, '"ntr"1 t"
p!y'%iatri'9Re%abi1itati"n ? %e1p patient t" 3nd a %"bbyand pr"d$'ti0e !5i11, %e1p patient t" intera'tn"r&a11y #it% %er )a&i1y and neig%b"r
97a&i1y ed$'ati"n ?9e=p1ain t" t%e )a&i1y ab"$t t%e &enta1di!"rder and t%e treat&ent.9Ed$'ate t%e )a&i1y t" !$pp"rt n"t t" e=i1e
t%e patient.9A!5 t%e )a&i1y t" &"nit"r patient pr"gre!!and &a5e !$re t%e patient ta5e &edi'ine a!pre!'ribe.
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%hank you