Morning Report 9 September 2013

7/26/2019 Morning Report 9 September 2013

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MORNINGREPORT

SUPERVISORdr. SABAR P. SIREGAR, SP.KJ

Monday, 9thSeptember 2013


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I. PATIENTS IDENTITY

AutoanamnesisName : Mr. AAge : 55 years olGener : maleAress : Magelang

O!!u"ation : #Putu$ SellerMarital status : Marrie%ast eu!ation : &unior 'ig( S!(ool)grauate*

AlloanamnesisName : Mr. SAge : +, years olRelation : Patients -rot(er


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T'E REASON 'Y T'E PATIENT

AS -RO/G'T TO 'OSPITA%

Rage0 1aneringalone


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2007 2012

PRESENT HISTORY

want to do household chores,Social withdrawal, goodutilization of leisure time,good self grooming.

Didnt want to do householdchores, Social withdrawal,poor utilization of leisure

time, good self grooming.

Angry without anyreason

Raged

Talk to herself

Decreased appetiteDifficult to sleep

Wandering alone

Angry without any

reason

Raged

Difficult to sleep

Decreased appetite


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3 daysago

Day ofadmission

PRESENT HISTORY

Didnt want to do householdchores, Social withdrawal ,poor utilization of leisuretime, good self grooming.

Didnt want to do householdchores, Social withdrawal,poor utilization of leisure

time, good self grooming.

Angry without anyreason

!andering alone

Difficult to sleep

Decreased appetiteDistur" his

neigh"oor

Raged

Angry without any

reason

Difficult to sleep

decreased appetiteThrowing his

neigh"oor#s ho$e

with stones


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PAST 'ISTORY


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EAR%Y 2'I%D'OOD P'ASE ),34 YEARS O%D*EAR%Y 2'I%D'OOD P'ASE ),34 YEARS O%D*Psychomotoric (NO VALID DATA)% T(ere 1ere no ali ata on "atients gro1t( an eelo"ment su!( as:

% 6rst time li7ting t(e (ea )43+ mont(s*% rolling oer )43+ mont(s*% Sitting )+38 mont(s*% 2ra1ling )+38 mont(s*% Staning )+38 mont(s*% 1al9ing3running )83; mont(s*

% (oling o


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Emotion (NO VALID DATA) T(ere 1ere no ali ata o7 "atients rea!tion 1(en

"laying0 7rig(tene


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INTERMEDIATE 2'I%D'OOD )43 YEARSINTERMEDIATE 2'I%D'OOD )43 YEARS

O%D*O%D*Psychomotor (NO VALID DATA)

No ali ata on 1(en "atients 6rst time riing a tri!y!le or


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%ATE 2'I%D'OOD @ TEENAGE%ATE 2'I%D'OOD @ TEENAGE

P'ASEP'ASESeual !evelo"ment signs # activity (NO VALID DATA) No ata on 1(en "atient e"erien!e 1et ream0 (air on arm"its an

"u


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AD/%T'OOD


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Stage Basic Conflict Important Events

(nfancy#)irth to 1* months'

Trust +s mistrust ,eeding

-arly childhood#2%3 years'

Autonomy +s shame and dou)t Toilet training

.reschool#3%/ years'

(nitiati+e +s guilt -ploration

chool age#$%11 years'

(ndustry +s inferiority chool

Adolescence#12%1* years'

(dentity +s role confusion ocial relationships

oung Adulthood

#1&%0 years'

(ntimacy +s isolation Relationship

Middle adulthood(40-65 ears!

"enerativit vs stagnation #or$ and parenthood

4aturity#$/% death'

-go integrity +s despair Reflection on life

5onclusion6 not clear data


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Camily 'istory

% Patient is t(e 4t( !(il o7 5 si


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Psy!(oseual (istory

% Patient psychosexual history isappropriate of his gender and attracted to

woman.


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:Female

:Male : RIP

: Patient

i+e together


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PROGRESSION OC DISORDER

Symptom

Role function

%00& ' das ago no%0)%%00*%00+ %0))


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Mental State)Monay 0 8t(Se"tem


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Behaviour

'y"oa!tieHyperactiveE!(o"raia2atatoniaA!tie negatiism2ata"leyStreoty"yMannerismAutomatism

-i?arre

2omman automatismMutismA!at(ysia

Ti!Somna


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ATTITUDE

Non3!oo"eratie

Ini7errentA"at(yTensionDe"enentActive

Passie

In7antileDistrust%a


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Emotion


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Distur


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T(in9ing t(oug(t "rogression


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2ontent o7 t(oug(t

(dea of Reference

.reocupation

:)session

.ho)ia

Delusion of .ersecution

Delusion of Reference

Delusion of -n+iousDelusion of ;ipokondry

.elusion of magic-mstic

.elusion of grandiose

Delusion of 5ontrol

Delusion of (nfluence

Delusion of .assi+ity

Delusion of .erception

Delusion of suspicious

Thought of -cho

Thought of (nsertion


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T(oug(t "ro!ess

Realisti!

Non RealisticDereisti!Autisti!


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Sensorium and Conition

%eel o7 eu!ation : enoug( General 9no1lege : enoug( Orientation o7

time"la!e"eo"lesituation:

googoogoogoo or9ings(ortlong memory: enoug( riting an reaing s9ills : not

!(e!9e Fisuos"atial : not !(e!9e A


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Internal Status

2on!iousnes : !om"osmentisFital sign :

-loo "ressure : +,8, mm'g

Pulse rate : 8 mnt

Tem"erature : a7e


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Head ! normocephali

Eyes ! anemic con"untiva #$#% icteric sclera #$#%

pupil isocore

Nec& ! normal% no riidity% no palpa'le lymph

nodes

Thora(!

Cor ! S )%* Sound and normal

+un ! vesicular sound% ,hee-in #$#% ronchi#$#

A'domen ! .ain /#0 % normal peristaltic% tympany

sound

E(tremity ! 1arm acral% capp re2ll 3*4


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DiBerential Diagnose

%,20"0 .aranoid chi=ophrenia

%,2/"0 chi=oaffecti+e disorder manic type


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5ultia(ial Dianose

Ais ( 6 ,2/"0 chi=oaffecti+e disorder manic type

Ais (( 6 R$"* diagnostic delayed ais ((

Ais ((( 6 tage 2 hypertension #>. ?1$0 or D>.

?100'Ais (@ 6 -conomic pro)lem #unsold his putuB '

Ais @ 6 CA, admission 20%11


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P%ANNINGP%ANNING

MANAGEMENTMANAGEMENTHospitali-ation

.harmacotherapy

.sycho#education


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P%ANNINGP%ANNING

MANAGEMENTMANAGEMENT

Hospitali-ationPatient is enangere to ot(er "eo"le


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P%ANNING MANAGEMENTP%ANNING MANAGEMENTP(arma!ot(era"y

OEmergen!y Room:3 In= Dia?e"am 5 mg IF3 In= 'alo"eriol 5 mg IM

ORoutine t(era"y3 'alo"eriol ; 5 mg3 2a"to"ril 4 ;5 mg


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P%ANNING MANAGEMENTP%ANNING MANAGEMENT.sycho#educationEducate the patient and family !

E(plain to patient6s family a'out mental disorder7 There are manyfactors cause the symptoms% such as chemical im'alance in the'rain% so ,e need various aspects for the treatment7Don6t force the patient to understand the family instead viceversa7Treat the patient accordin to the family6s a'ility% don6t demand

the patient more nor less7Help the patient ,hen he needs it7Education of the family to encourae communication andunderstandin78eep the patient a,ay from o'"ects that can harm other peopleand patient7


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Than&9ou:

Morning Report 9 September 2013

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