Download - 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: