Morning Report Dels Edits

8/18/2019 Morning Report Dels Edits

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M O N D A Y M A R C H 2 N D , 2 0 1 5

S U P E R V I S O R :D R . S A B A R S I R E G A R , S P . K J

MORNING REPORT

Della Putri AriyaniTara Wandhita Usman

030.09.061030.09.250FK TR !AKT



PATIENT’S IDENTITY

1. Name : Mr. W2. Age : 28 years old3. Sex : Male4. Address : Purbalingga5. Job : nem!loyed". Mari#al s#a#us : Single

$. %#&ni'i#y : Ja(anese8. %du'a#ional s#a#us : %lemen#ary S'&ool



GUARDIAN IDENTITYALLOANAMNESIS WAS CONDUCTED TO :

1. Name : Miss. S2. Age : 23 years old3. Sex : )emale

4. Address : Purbalingga5. Job : SP*". %du'a#ion : Senior +ig& S'&ool$. Mari#al s#a#us : Single

8. %#&ni'i#y : Ja(anese,. -ela#ion : Sis#er



REASON BROUGHT TO HOSPITAL

• Patient was brought by his guardianbe ause he ra!"age and angry with

out any reason# then $e wants to %i&& his "arent'



ST(ESSO(

• Un &ear



PROGRESSION OF ILLNESS

2011(4 years

ago)

• After came back fr m!a"#$"%, t&e 'at(e"t c&a"%e&() be&a*( r+

• He be%(" t ta k a"# a$%& b-&() )e f+

•

He #(#".t % t / rk a"# &e() ate# &(m)e f+




2012(3 years

ago)

• &e )-m't m) )t( )ame

• &e fam( - #(#".t t&("k t&at)/a) (t) " t )er( $) ( "e), )t&e fam( - #(#" t br $%&t &(mt t&e & )'(ta +




2013(2 years

ago)

• &e )-m't m) )t( )ame

• &e fam( - #(#".t t&("k t&at)/a) (t) " t )er( $) ( "e), )t&e fam( - #(#" t br $%&t &(mt t&e & )'(ta +




September 2014(5 month

ago)

• Start t k) /e(r#, ) met(me) k)afra(# /(t& $t a"- rea) "

• Pat(e"t fte" t )cream /(t& $t a"-rea) ", ) met(me) ram'a%e a"#a"%r-, A m )t a /a-) k)fr(%t&e"e# a t&e t(me beca$)ee*er- "e t&("k) &e () a ba# %$-+

•

He )$re ) met&("% )car- a /a-) tr-t c "tr a"# (" $e"ce &(m, e"ter t&() m("#, a"# c "#$ct &(m t #) met&("% & rr(b e )$c& a) ram'a%e,a"# tr- t k( ) me "e

• He )$re e*er-b #- k" / /&at.) "&() m("#, a"# tr- t t&reate" &(m

• (m(te# ) c(a ("teract( ", ' r )e f%r m("%, a"# ) ee' #() r#er 3&eca".t )tart t ) ee'4+




• Pat(e"t )tart t ram'a%e a"#

)cream /(t& $t a rea) ", He tr- t

k( &() 'are"t)+ He #(# (t beca$)eHe fee ) t&e 'e ' e arr $"# &(m tbe t&reat &(m, t&at) /&- &e taket&e k"(fe a"# tr- t k( t&em+

• (m(te# ) c(a ("teract( " a"#act(*(t-, ' r )e f %r m("%, ca".t) ee'

1 daysbefore

patient’s

admissi

on



T$E DA) O* ADMISSION

• $is guardian an+t ontro& hi! any!ore be ause he ta%e the %ni,e and try to %i&& his "arent# so she de ided tobrought hi! to (S- Soero.o Mage&ang'



HISTORY OF PAST ILLNESS

• Psychiatric illness There is no history o, " y hiatri i&&ness' General e!ical illness

There is no history o, high ,e/er# sei0ure# head trau!a# or any other serious i&&ness whi h needs hos"ita&i0ation

• S"#stance a#"seThere is no history about a& oho& use# drug abuse or s!o%ing $




!ym"t#ms

R#leFun$ti#n

2011eb2015Se' 2016



FAMILY HISTORY

• There is no history o, "sy hiatri i&&ness in her ,a!i&y'

•

There is no history o, high ,e/er# sei0ure#head trau!a# or any other serious i&&nesswhi h needs hos"ita&i0ation



1ENO1(AM



HISTORY OF PERSONAL LIFE

• Prenatal an! %erinatalThere was no /a&id data in "atient+s "renata&and "erinata& as"e t# su h as :

Patient+s !other+s age and ondition whenshe was "regnantPatient+s !other+s de&i/ery history and "atie

nt+s "erinata& ondition'Patient+s i!!uni0ation status




• Early chil!h&&! %hase '()* years &l!+Psy ho!otor

• There was no /a&id data in "atient+s "sy ho!otor as"e t 2su h as ti&ting the body# su"ine to "rone# sitting# standing# wa&%ing# s!i&ing# ho&ding her own hand# s oo" u" ob.e t# ho&ding "en i& and "i&&ing u" two ob.e ts3

Psy hoso ia&• There was no /a&id data in "atient+s "sy hoso ia& as"e t 2su h as re"&ying to s!i&

e# s!i&ing when seeing interesting ob.e t# "&aying i&u%ba# %nowing her ,a!i&y !e!bers and "ointing what she wanted without rying3

Co!!uni ation• There was no /a&id data in "atient+s o!!uni ation as"e t 2su h as bubb&ing# o

oing# !a%ing sounds without !eaning# te&&ing 456 sy&&ab&es without !eaning an

d a&&ing !a!a7"a"a3E!otion• There no /a&id data in "atient+s e!otion as"e t 2su h as when "atient "&aying# ,ri

ghtened by strangers# starting to show .ea&ousy or o!"etiti/eness towards other# and toi&et training3

• Patient didn+t "ee or de,e ate in her "ants when she was two years o&dCogniti/e

• There was no /a&id data in "atient+s ogniti/e as"e t 2su h as o"ying sounds tha




• Early chil!h&&! %hase '()* years &l!+Psy ho!otor

• There was no /a&id data in "atient+s "sy ho!otor as"e t 2su h as ti&ting the body# su"ine to "rone# sitting# standing# wa&%ing# s!i&ing# ho&ding her own hand# s oo" u" ob.e t# ho&ding "en i& and "i&&ing u" two ob.e ts3

Psy hoso ia&• There was no /a&id data in "atient+s "sy hoso ia& as"e t 2su h as re"&ying to s!i&

e# s!i&ing when seeing interesting ob.e t# "&aying i&u%ba# %nowing her ,a!i&y !e!bers and "ointing what she wanted without rying3

Co!!uni ation• There was no /a&id data in "atient+s o!!uni ation as"e t 2su h as bubb&ing# o

oing# !a%ing sounds without !eaning# te&&ing 456 sy&&ab&es without !eaning an

d a&&ing !a!a7"a"a3E!otion• There no /a&id data in "atient+s e!otion as"e t 2su h as when "atient "&aying# ,ri

ghtened by strangers# starting to show .ea&ousy or o!"etiti/eness towards other# and toi&et training3

• Patient didn+t "ee or de,e ate in her "ants when she was two years o&dCogniti/e

• There was no /a&id data in "atient+s ogniti/e as"e t 2su h as o"ying sounds tha




• Inter e!iate chil!h&&! %hase '*),, years &l!+Psy ho!otor

No /a&id data on when "atient ,irst ti!e &i!bing the tree or "&ay hide and see% ga!es# and i, "atient e/er in/o&/ed in any %ind o, s"orts'

Psy hoso ia&There were no /a&id data on "atient+s gender identi,i ation#intera tion with his surrounding' There were no data on when "atient ,irst entered "ri!ary s hoo&# how we&& "atient hand&e se"aration ,ro! "arents# how we&& he "&ays with new ,

riends on ,irst day o, s hoo&Co!!uni ation

There were no /a&id data regarding "atient+s abi&ity to!a%e ,riends in s hoo&# and how !any ,riends "atient ha/eduring her s hoo&ing "eriod'




• Inter e!iate chil!h&&! %hase '*),, years &l!+

E!otionNo /a&id data on "atient ada"tation under stress

Cogniti/eNo /a&id data on "atient+s grades in s hoo&



HISTORY OF PERSONAL LIFE• Late chil!h&&! an! teena-e %hase ',,),. years &l!+

Psy ho!otorNo data i, "atient had any ,a/orite hobbies or ga!es# i, "atien

t in/o&/ed in any %ind o, s"orts'Psy hoso ia&

"atient e/er had any re&ationshi" with o""osite gender'Co!!uni ation

No /a&id data on how we&& the re&ationshi" between "atient with "arents and other ,a!i&y'

E!otionNo data i, "atient e/er to&d ,riend or ,a!i&y regarding any "rob&e!s'No data i, "atient atte!"ted to brea% the ru&es 2truant s hoo& sub.e

t# ,ight with ,riends# bu&&ying# e t3 and onsu!ing a& oho&# s!o%e and drugs

Cogniti/e•

A,ter graduating ,ro! e&e!entary s hoo&# "atient did not go to shoo& any!ore



HISTORY OF PERSONAL LIFE• A!"lth&&! %hase ',. years &l!)n&/+

Edu ationa&• Patient graduated ,ro! e&e!entary s hoo&O u"ationa&

• *ar!er'Marita& status

• Patient has !arried'Cri!ina&

• She has no ri!ina& historyCurrent situation

• Patient &i/e with his ,a!i&y'



ERI0SON’S STAGES OF PSY1HOSO1IAL DE2ELOPMENT

Sta%e !a)(c C " (ct Im' rta"t E*e"t)

I"fa"c-3b(rt& t 17 m "t&)4 r$)t *) m()tr$)t ee#("%

Ear - c&( #& #3289 -ear)4

A$t " m- *) )&amea"# # $bt ( et tra("("%

Pre)c&

3985 -ear)4I"(t(at(*e *) %$( t E ' rat( "

Sc& a%e3;811 -ear)4 I"#$)tr- *) ("fer( r(t- Sc&

A# e)ce"ce312817 -ear)4

I#e"t(t- *) r ec "f$)( " S c(a re at( ")&(')

Y $"% A#$ t& #31<860 -ear)4

I"t(mac- *)() at( " Re at( ")&('

M(## e a#$ t& #3608;5 -ear)4

=e"erat(*(t- *))ta%"at( "

> rk a"#'are"t& #

Mat$r(t-3;58 #eat&4 E% ("te%r(t- *) #e)'a(r Re ect( " " (fe



E3AMINATIONM O ( N I N 1 ( E P O ( T

S AT U ( D A) * E 8 4 9 T $ # 4 ; <



PHYSI1AL E3AMINATIONMO(NIN1 (EPO(T



GENERAL PHYSI1AL E3AMINATION

• General a%%earance :he &oo%s in good status

• 2ital si-n :8P : ;4 7= !!$g$( :=;>7!

t o : a,ebris(( : 4 >7!



GENERAL PHYSI1AL E3AMINATION

Hea! :nor!o e"ha&i# !outh de/iation 253

ane!i on.ungti/a 253# i teri s &era 253# "u"i& iso ore

Nec4 : nor!a&# no rigidity# no "a&"ab&e &y!"h nodes

Th&ra5 :Cor : S; S4 regu&ar# !ur!ur 5# ga&&o" ?Lung : /esi u&ar sound @7@# whee0ing 575# ron hi575

A#!& en :,&at# abdo!ina& wa&&77 hest wa&&# nor!a& "erista&ti # ty!"any sound# tender

ness 5# !ass 5# &i/er# s"&een and %idney not "a"ab&e

E5tre ity : War! a ra&# a"" re,i&& 4B# ede!a 253



NEUROLOGI1AL E3AMINATION

• Le6el &7 1&nsci&"sness :• o!"os !entis# E <M 2;<3

• General A%%earance 8• 8ody "osture : nor!a&• Abnor!a& !o/e!ent : 5•

Wa&%ing sty&e : nor!a&




• 1ranial ner6es e5a inati&n8• CN I : in nor!a& ,inding• CN II : in nor!a& ,inding•

CN III#I # I : in nor!a& ,inding• CN : in nor!a& ,inding• CN II : in nor!a& ,inding• CN III : in nor!a& ,inding• CN IF : in nor!a& ,inding• CN F : in nor!a& ,inding• CN FI : in nor!a& ,inding• CN FII : in nor!a& ,inding




• M&t&ricU""er e>tre!ities: tonus 2@3# tro"hy : eutro"hi # "ower o, !o/e!ent : shou&der .oint : <# e&bow .oint : <# wrist .oint : <# radia& ner/e ,un tion : <# u&nar ner/e ,un tion : <# !edian ner/e ,un tion : <

Lower e>tre!ities: tonus 2@3# tro"hy : eutro"hi # "ower o, !o/e!ent : hi" .oint : <# %nee .oint : <# an%&e .oint : <

• Sens&ri"DCML syste! : "ro"rio e"tion# ,ine tou h : no abnor!a&itiesAL syste! : /ibration# te!"erature# rude tou h# "ain : no abnor!a&ities




• Physi&l&-ical re7le5U""er e>tre!ities: bi e"s re,&e> 2@3# tri e"s re,&e> 2@3# bra hioradia& 2@3Lower e>tre!ities: "ate&&a re,&e> 2@3# a hi&&es tendon re,&e> 2@3

• Path&l&-ical re7le5U""er e>tre!ities: $o,,!an 253# Tro!ner 253Lower e>tre!ities: babins%i 253# haddo% 253#gordon 253#o""enhei! 253# rosso&i!o 253# &onus 575

• Menin-eal si-nNe % sti,,ness 253# brud0ins%i ne % sign 253# brud0ins%i ontra&atera& &eg sign 253# %ernig sign 253

• 1ere#ell" 7"ncti&nAdhyado%o%inesia 253# ro!berg test 253# ,inger to nose test 2no abnor!a&ities3# ti" to toe wa&% 2no abnor!a&ities3



MENTAL STATE E3AMINATIONM O ( N I N 1 ( E P O ( T

S AT U ( D A) * E 8 ( U A ( ) 4 9 T $ # 4 ; <



GENERAL APPEARAN1E

A Man# age 49 years o&d# a""ro"riate to his age# tension# and wearing good &oth# "oor se&, groo!ing



ORIENTATION

• Ti!e : good• Peo"&e : good• P&a e : good• Situation : good

Consciousness• C ear



BEHA2IOR

• Hy%&acti6e• $y"era ti/e• E ho"ra>ia• Catatonia• A ti/e negati/is!• Cata"&e>y• Streoty"y•

Manneris!• Auto!atis!• 8i00are• Co!!and auto!atis!• Mutis!• A athysia• Ti• So!nabu&is!• Psy ho!otor agitation• Co!"u&si/e• Ata>ia• Mi!i ry• Aggresi/e• I!"u&si/e• Abu&ia



ATTITUDE

• 1&&%erati6e• Non5 oo"erati/e• Indi,errent• A"athy• Tensi&n• De"endent• Passi/e• In,anti&e• Labi&e• (igid•

Passi/e negati/is!• Stereoty"y• Cata&e"sy• Cerea ,&e>ibi&ity• E> ited



EMOTION

M #• Dysphoric• De're))e#• E$t&-m(c• E e*ate#• E$'& r(a• Irr(tab e• A%(tat( "

A?ect

• !r a#• Re)tr(ct(*e• ! $"te#• !at• ab( e



DISTURBAN1E IN PER1EPTION

"a!!ucination

• #uditory ($)• %isua! ($)• O fact r- 384• =$)tat r- 384• act( e 384• S mat(c 384

&!!usion

• A$#(t r- 384• %isua! ($)• O fact r- 384• =$)tat r- 384• act( e 384• S mat(c 384

De'er) "a (@at( " 384 Derea (@at( " 384



PROGRESSION OF THOUGHT'uantity

• % rr&ea• ! ck("%• emming• M$t()m

• a kat(*e

'ua!ity

• Coherence• Irre e*a"t a")/er• C 'r a (a• I"c &ere"ce• (%&t f (#ea•

o*erty of speech• C "fab$ at( "• )e"("% f a)) c(at( "• Ne %()me• C(rc$mta")(a (t-•

a"%e"t(a (t-• Verb(%rat( "• Per)e*erat( "• S $"# a)) c(at( "• > r# )a a#• Ec& a (a



1ONTENT OF THOUGHT

• I#ea f Refere"ce• Pre cc$'at( "• Ob)e))( "•

P& b(a• a"ta)-• De $)( " f Per)ec$t( "• De $)( " f Refere"ce• De $)( " f E"*( $)• De $)( " f H-' c& "#r(ac• De $)( " f Ma%(c8m-)t(c•

I#ea f )$(c(#a

• De $)( " f =ra"#( )e• De!usion of Contro!• De $)( " f Re (%( "•

De!usion of &n+uence• De $)( " f Pa))(*(t-• De!usion of Suspicion• I#ea f S$)'(c( "• ,hought of -cho• & $%&t f I")ert( "• & $%&t f /(t&#ra/a•

,hought of .roadcasting



FORM OF THOUGHT

• N&n Realistic• Dereisti•

Autis!• Cannot be e/a&uated



1OGNITI2E FUN1TION

Le/e& o, edu ation : ,inished e&e!entary s hoo& 1enera& %now&edge : good Wor%ing7short7&ong !e!ory : good

Writing and reading s%i&&s : good isuos"atia& : good Abstra t thin%ing : "oor Abi&ity to se&, are : "oor



IMPULSE 1ONTROL 9HEN E3AMINED

• Se&, ontro&: Enough• Patient res"onse to e>a!iners Guestion: good

&nsight• Im'a(re# (")(%&t 3'at(e"t #(# " t

k" / t&at &e () me"ta - ( 4• &nte!!ectua! &nsight• r$e I")(%&t



RESUMEMO(NIN1 (EPO(T

Patient %as &r#u'ht &y his 'uardian &e$ause he ram"a'e and an'ry



Symptom/ enta! Status/ &mpairment/• ta k a"# a$%& b- &()

)e f • Ram'a%e a"# a"%r-

/(t& $t a"- rea) "• He /a"t) t k( &()

'are"t• He a /a-) k)

fr(%t&e"e# a t&e t(mebeca$)e e*er- "et&("k) &e () a ba# %$-+

• He )$re ) met&("% )car-a /a-) tr- t c "tr a"#(" $e"ce &(m, e"ter t

&() m("#, a"# c "#$ct&(m t # ) met&("%& rr(b e )$c& a)ram'a%e, a"# tr- t k() me "e

• He )$re e*er-b #- k" /

/&at &e () t&("k("%, a"#tr t t&reate" &(m

• !e&a*( r : H-' act(*e•

M # : D()f r(k• A?ect : at• Pr %re))( " f

& $%&t:Remm("%,c &ere"ce, ' *ert-)'eec&

• Ha $c("at( " :

#uditory 3&$mm("%4 %isua! 3 )ee &() fr(e"#t("( a"# '$tr( ama (a t&e ' a"# t tr- k( &er+ 4

• C "te"t f t& $%&t :t& $%&t ec& , #e $)( "

f c "tr , #e $)( " f(" $e"ce, #e $)( " f)$)'(c( "+

• rm f t& $%&t : " "rea ()t(c

• I")(%&t: I"te ect$a(")(%&t

• Pat(e"t

(m(te#) c(a (@e /(t&t&er)

• Pat(e"t ca".t/ rk

• Pat(e"t ca".t

) ee'

y y%ith#ut any reas#n( then )e %ants t# *ill his "arent.



DIAGNOSISMO(NIN1 (EPO(T



S)ND(OME

• Thought e ho• Thought broad asting• Auditori% $a&usination• isua& $a&usination• De&usion o, Contro&• De&usion o, in,&uen e

• Auditory $a&usination: hu!!ing• De&usion o, ontro&• De&usion o, in,&uen e• De&usion o, Sus"i ion

!$hi+#"hreniasyndr#me

!$hi+#"hrenia"aran#id syndr#me



• Dis,ori%• (e!!ing• $y"oa ti/e•

Po/erty o, s"ee h• S&ee" disorder

De"resi#nsyndr#me



DIFFERENTIAL DIAGNOSIS

• *4 ' Paranoid S hi0o"hrenia• *4<'; S hi0oa,,e ti/e disorder de"resion ty"e



MULTIA3IAL DIAGNOSIS

• A>is I : *4 ' Paranoid S hi0o"hrenia• A>is II : ( '9 De&ayed diagnosis• A>is III: No diagnose•

A>is I : Stressor un &ear• A>is : 1A* ad!ission 6 54;



PATIENT’S PROBLEMS

• Bi&l&-ical %r&#lePositi/e sy!"to!s be ause o, an in rease in do"a!ine a!ount in the "ost syna"ti neuron

• Psych&l&-ical %r&#le sun &ear

• S&cial %r&#lehe an+t so ia&i0e we&& with others



MANAGEMENTMO(NIN1 (EPO(T



PLANNIN1 MANA1EMENT



MANAGEMENT PLANNING

• H&s%itali:ati&nPatient was hos"ita&i0ed be auseAngry and ra!"age without any reason'$e wants to %i&& his "arents

E er-ency De%art entIn.' $a&o"erido& < !g ; A!" IMIn.' Dia0e"a! < !g ; A!" I

Suggest ECT



RESPONSE PHASE

Tar-et Thera%y • < H de rease o, sy!"to!s

Maintenance Thera%y • $a&o"erido& tab <!g 4>;



(EMISSION P$ASE

• Tar-et thera%y 8; H re!ission o, sy!"to!

• In%atient ana-e ent$a&o"erido& tab <!g 4>;

I!"ro/ing the "atient Gua&ity o, &i,e :• Tea h "atient about her so ia& en/iron!ent 2intera t with her ,a

!i&y# so ia&i0e with her neighbor or ,riends# ,ind a hobby to do on her s"are ti!e3

• O"t%atient ana-e entContinuation o, "har!a othera"yPsy hoso ia& thera"y



RE1O2ERY PHASE

• Continue the !edi ation# ontro& to "sy hiatrist• (ehabi&itation :

- Consu&t to "sy ho&ogist to he&" "atient ,inding a hobby- $e&" "atient to intera t nor!a&&y with her ,a!i&y and neighbor



FAMILY EDU1ATION

• E>"&ain to the ,a!i&y that anyone ou&d ha/e !enta& disorders• Menta& disorders are aused by !u&ti,a toria& ,a tor# not on&y b

y geneti inheritan e• Menta& disorders !ost&y are a,,e ted by he!i a& i!ba&an e in

brain• Menta& disorders an be ontro&&ed by !edi ines# so it is i!"ort

ant to ta%e the !edi ines routine&y• Treat "atient &i%e you treat any other "eo"&e•

$e&" "atient i, she shou&d be he&"ed• Don+t "ush "atient to understand the ,a!i&y# but her ,a!i&y that has to understand her

• Don+t be too e!otiona& to "atient



M O N D AY M A R C H 2N D

, 2 0 1 5

THAN0 YOU;

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