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7/28/2019 Morning Report 15mar13
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Supervisor : dr. Sabar P Siregar Sp.KJ
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Autoanamnesis
Name :Mr. RAge :38 years old
Gender : MaleAddress :Temanggung Occupation :Not work Marital status :Married Religion :Moslem Last education :
Elementary School
Name :Mr. SAge :30 years old
Relation :Brother
Alloanamnesis
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CHIEF COMPLAINT
AFRAID
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4 months ago
Afraid, angry, sleep disorder (difficult tosleep), talk to himself, hear a sound that say
want to kill him
Poor grooming, Unemployed
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HISTORY OF PRESENTING ILLNESS
4 months ago
AfraidAngry
sleep disorder (difficult to sleep)talk to himselfhear a sound that say want to kill him
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PAST ILLNESS HISTORY
Psychiatry history
He comes for the first time
General medical history
Hypertension (+) Head injury (-)
Convulsion (-)
Asthma (-)
Allergy (-)
Drugs and alcohol abuse history and smoking history Alcohol consumption (-)
Tobacco consumption (-).
Drugs abuse (-)
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PRENATAL AND PERINATAL HISTORY
No valid datawhether the mother has sufficientnutricient during pregnancy and routine vitamincapsule during pregnancy
No valid datawhether she has stabile emotional
condition during this pregnancy
No valid datawhether every month she goes toprimary health care to check her pregnancy
No valid datawhether she has no significantmedical problem such as profuse vomitus , fever,high blood pressure, seizure, leukorea and bleeding
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EARLY CHILDHOOD PHASE
(0-3 YEARS OLD)
Psychomotoric
There were no valid data on patients growth and developmentsuch as: first time lifting the head, rolling over, sitting, crawling,standing, walking-running, holding objects in her hand, putting
everything in her mouth, holding objects in her handPsychosocial
There were no valid dataon which age patient started smilingwhen seeing another face, startled by noises, when the patientfirst laugh or squirm when asked to play, nor playing claps withothers
Communication
There were no valid dataon when patient started saying wordslike mom or dad, or talks.
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Emotion
There were no valid data of patients reaction whenplaying, frightened by strangers, when starting toshow jealousy or competitiveness towards other andtoilet training.
Cognitive 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 firstcopied sounds that were heard, or understandingsimple orders
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Intermediate Childhood
(3-11 years old)
Psychomotor
No valid dataon when patients first time riding a tricycle or bicycle, ifpatient ever involved in any kind of sports.
Psychosocial
There were no data on patients gender identification, interaction with her
surroundings
Patient enter elementary school at 8 years old Communication
There were no valid data regarding patients ability to make friends in
school, and how many friends patient have during her schooling period.
Emotional
No valid data on patients adaptation under stress, any incidents ofbedwetting were not known.
Cognitive
Patient didnt graduated from 1st grade of elementary school
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Late Childhood & Teenage Phase Sexual development signs & activity
No valid data on when patient experience wet dream, hair on armpitsand pubis, etc
Psychomotor
No valid data if patient had any favourite hobbies or games, if patientinvolved in any kind of sports.
Psychosocial
No valid data if while growing up did he make many friends, how well
patient make any friends and how much friends. No valid data on when and how patients relationship with different
gender, if patient ever had any relationship with the opposite gender.
Emotional
No valid data if patient ever told friends or family regarding any
problems. No valid data if patient attempted to break the rules (truant schools
subject, fight with friends, bullying, etc) and consuming alcohol, smokeand drugs
Communication
No valid data on how well the relationship between patient with parents
and other family. 11
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Adulthood
Educational history
Patient hasnt graduated from elementary school
Marriage status
married, but not lived togehter.
Legal historyNo data
Social activity
have normal social activity
Current situationHe live with his mother and brother
Religion history
He prays daily until now
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Family History
There was not any history of psychiatric
disorder in his family, his father, mother,
brother, and his son
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Psychosexual history
Patient psychosexual history is appropriate
of his gender and attracted to girl
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:Female
:Male: RIP
: Mental illnes family ever
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Economic
scale:low
Socio-economic
historyAlloanamnesis
: valid
Autoanamnesi
: valid
Validity
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Mental State 15th March 2013
Appearance :
man , appropriate according to age, poor grooming
State of Consciousness
Clear
Speech:
Quantity : Enough
Quality : Enough
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Behaviour
Normoact ive
Hypoactive
Hyperactive
Echopraxia
CatatoniaActive negativism
Cataplexy
Streotypy
Mannerism
AutomatismBizzare
Command automatismMutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
AggresiveImpulsiveAbulia
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Attitude
Cooperative
Non-cooperative
Indiferrent
Apathy Tension
Dependent
Active
Passive
InfantileDistrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibilityExcitement
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Emotion
Mood
Euthymic
Hipothym Dysphor ic Euphoria
Elevated
Expansive Irritable
Cant be assesed
Affect
Appropr ia te
Inappropriate
Restrictive Blunted
Flat
Labile
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Disturbance of perception
Hallucination
Auditory (+) paranoid Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-) Somatic (-)
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
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Thinking thought progression
Quantity
Logorrhea
Blocking
Remming Mutisme
Talk active
Quality
Irrelevan answer
Incoherence
Flight of idea
Confabulation
Poverty of speech Loosening of association
Neologisme
Circumtansiality Tangential
Verbigrasi
Perseverasi
Sound associationWord salad
Echolalia
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Thought Process content of thought
Idea of Reference
Preoccupation
Obsession
Phobia Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hipokondry
Delusion of magic-mystic
Delusion of grandiose
Delusion of Control
Delusion of Inf luence
Delusion of Passivity Delusion of Perception
Delusion of suspicious
Thought of Echo
Thought of Insertion/withdrawal
Thought of Broadcasting
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Thought process
Realistic
Non Realistic
Dereistic
Autism
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Sensorium and Cognition
Level of education : low
General knowledge : low
Orientation of time/place/people/situation:
enough/enough/enough/enough Working/short/long memory: enough
Writing and reading skills : low
Visuospatial : low
Abstract thinking : low
Ability to self care : low
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Self control : good
Patient response toexaminers question:
good
Impulse controlwhen examined
Impaired insight
Intelectual Insight True Insight
Insight
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Internal Status Conciousness: compos mentis Vital sign:
Blood pressure : 140/80 mmHg
Pulse rate : 62 x/mntTemperature : afebris
RR : 20 x/mnt
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Head : normocephali
Eyes : anemic conjungtiva -/-, icteric sclera -/-, pupil isocor
Neck : normal, no rigidity, no palpable lymph nodes
Thorax:
Cor : S1,2 Sound and normal
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill
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Neurological status
Motoric : not tested
Physiological reflex : not tested
Pathological reflex : not tested
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Onset Mental state Impairment
4 months agoAfraid, angry, sleepdisorder (difficult tosleep), talk to himself,hear a sound that say
want to kill him
Attitude : tension- Mood :disforic-Affect : appropriate-Speech :
quantity : enough
quality :enough-Disturbacens of perception :auditory hallucination,-Thought content : delution ofreference
-Thought form : non realistic-Insight : true insight
2 months agooRole function: pooroPsychosocial: pooroAbility to self care:poor grooming
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Significant Finding Resume
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Multiaxial Diagnose
Axis I : F20.0 schizophrenia paranoidAxis II : R46.8 diagnosis axis II delay
Axis III : I.00 I.99 circulation system
disorder (hypertension)
Axis IV : problem with family (left by hiswife and son)
Axis V : GAF admission 30 - 21
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Hospitalization To establish an effective association between patients and community support
systems
Hospital treatment plans should be oriented toward practical issues of self-care,quality of life, employment, and social relationships.
FAMILY EDUCATION :
- explain to the patient about test results.
- explained to the patient's family know about this :
1. Severe mental disorder can be unsettled on anyone and can be caused by a numberof biological, social factors and organic2. Do not let the patient alone and treated like normal
3. Help if the patient need help but not passive.4. Not too much advise.
5. Families must understand the patient.
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Initial Therapy:
Lodomer 1 amp IM
-Room: Haloperidol 2 x 5 mg
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