morning report dels edits
TRANSCRIPT
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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
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PATIENT’S IDENTITY
1. Name : Mr. W2. Age : 28 years old3. Sex : Male4. Address : Purbalingga5. Job : nem!loyed". Mari#al s#a#us : Single
$. %#&ni'i#y : Ja(anese8. %du'a#ional s#a#us : %lemen#ary S'&ool
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GUARDIAN IDENTITYALLOANAMNESIS WAS CONDUCTED TO :
1. Name : Miss. S2. Age : 23 years old3. Sex : )emale
4. Address : Purbalingga5. Job : SP*". %du'a#ion : Senior +ig& S'&ool$. Mari#al s#a#us : Single
8. %#&ni'i#y : Ja(anese,. -ela#ion : Sis#er
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REASON BROUGHT TO HOSPITAL
• Patient was brought by his guardianbe ause he ra!"age and angry with
out any reason# then $e wants to %i&& his "arent'
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ST(ESSO(
• Un &ear
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PROGRESSION OF ILLNESS
2011(4 years
ago)
• After came back fr m!a"#$"%, 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+
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PROGRESSION OF ILLNESS
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 +
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PROGRESSION OF ILLNESS
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 +
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PROGRESSION OF ILLNESS
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+
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PROGRESSION OF ILLNESS
• 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 $"# &(m tbe t&reat &(m, t&at) /&- &e taket&e k"(fe a"# tr- t k( t&em+
• (m(te# ) c(a ("teract( " a"#act(*(t-, ' r )e f %r m("%, ca".t) ee'
1 daysbefore
patient’s
admissi
on
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T$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'
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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 $
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PROGRESSION OF ILLNESS
!ym"t#ms
R#leFun$ti#n
2011eb2015Se' 2016
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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
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1ENO1(AM
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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
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HISTORY OF PERSONAL LIFE
• 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
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HISTORY OF PERSONAL LIFE
• 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
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HISTORY OF PERSONAL LIFE
• 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'
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HISTORY OF PERSONAL LIFE
• 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&
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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
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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'
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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
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E3AMINATIONM O ( N I N 1 ( E P O ( T
S AT U ( D A) * E 8 4 9 T $ # 4 ; <
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PHYSI1AL E3AMINATIONMO(NIN1 (EPO(T
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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!
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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
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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&
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NEUROLOGI1AL E3AMINATION
• 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
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NEUROLOGI1AL E3AMINATION
• 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
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NEUROLOGI1AL E3AMINATION
• 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
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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 ; <
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GENERAL APPEARAN1E
A Man# age 49 years o&d# a""ro"riate to his age# tension# and wearing good &oth# "oor se&, groo!ing
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ORIENTATION
• Ti!e : good• Peo"&e : good• P&a e : good• Situation : good
Consciousness• C ear
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BEHA2IOR
• Hy%&acti6e• $y"era ti/e• E ho"ra>ia• Catatonia• A ti/e negati/is!• Cata"&e>y• Streoty"y•
Manneris!• Auto!atis!• 8i00are• Co!!and auto!atis!• Mutis!• A athysia• Ti• So!nabu&is!• Psy ho!otor agitation• Co!"u&si/e• Ata>ia• Mi!i ry• Aggresi/e• I!"u&si/e• Abu&ia
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ATTITUDE
• 1&&%erati6e• Non5 oo"erati/e• Indi,errent• A"athy• Tensi&n• De"endent• Passi/e• In,anti&e• Labi&e• (igid•
Passi/e negati/is!• Stereoty"y• Cata&e"sy• Cerea ,&e>ibi&ity• E> ited
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EMOTION
M #• Dysphoric• De're))e#• E$t&-m(c• E e*ate#• E$'& r(a• Irr(tab e• A%(tat( "
A?ect
• !r a#• Re)tr(ct(*e• ! $"te#• !at• ab( e
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DISTURBAN1E IN PER1EPTION
"a!!ucination
• #uditory ($)• %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• =$)tat r- 384• act( e 384• S mat(c 384
De'er) "a (@at( " 384 Derea (@at( " 384
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PROGRESSION OF THOUGHT'uantity
• % rr&ea• ! ck("%• emming• M$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 $"# a)) c(at( "• > r# )a a#• Ec& a (a
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1ONTENT OF THOUGHT
• I#ea f Refere"ce• Pre cc$'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( "• & $%&t f /(t&#ra/a•
,hought of .roadcasting
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FORM OF THOUGHT
• N&n Realistic• Dereisti•
Autis!• Cannot be e/a&uated
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1OGNITI2E FUN1TION
Le/e& o, edu ation : ,inished e&e!entary s hoo& 1enera& %now&edge : good Wor%ing7short7&ong !e!ory : good
Writing and reading s%i&&s : good isuos"atia& : good Abstra t thin%ing : "oor Abi&ity to se&, are : "oor
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IMPULSE 1ONTROL 9HEN E3AMINED
• Se&, ontro&: Enough• Patient res"onse to e>a!iners Guestion: good
&nsight• Im'a(re# (")(%&t 3'at(e"t #(# " t
k" / t&at &e () me"ta - ( 4• &nte!!ectua! &nsight• r$e I")(%&t
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RESUMEMO(NIN1 (EPO(T
Patient %as &r#u'ht &y his 'uardian &e$ause he ram"a'e and an'ry
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Symptom/ enta! Status/ &mpairment/• ta k a"# a$%& 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.
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DIAGNOSISMO(NIN1 (EPO(T
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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
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• Dis,ori%• (e!!ing• $y"oa ti/e•
Po/erty o, s"ee h• S&ee" disorder
De"resi#nsyndr#me
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DIFFERENTIAL DIAGNOSIS
• *4 ' Paranoid S hi0o"hrenia• *4<'; S hi0oa,,e ti/e disorder de"resion ty"e
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MULTIA3IAL DIAGNOSIS
• A>is I : *4 ' Paranoid S hi0o"hrenia• A>is II : ( '9 De&ayed diagnosis• A>is III: No diagnose•
A>is I : Stressor un &ear• A>is : 1A* ad!ission 6 54;
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PATIENT’S PROBLEMS
• Bi&l&-ical %r&#lePositi/e sy!"to!s be ause o, an in rease in do"a!ine a!ount in the "ost syna"ti neuron
• Psych&l&-ical %r&#le sun &ear
• S&cial %r&#lehe an+t so ia&i0e we&& with others
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MANAGEMENTMO(NIN1 (EPO(T
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PLANNIN1 MANA1EMENT
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MANAGEMENT PLANNING
• H&s%itali:ati&nPatient was hos"ita&i0ed be auseAngry and ra!"age without any reason'$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
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RESPONSE PHASE
Tar-et Thera%y • < H de rease o, sy!"to!s
Maintenance Thera%y • $a&o"erido& tab <!g 4>;
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(EMISSION P$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
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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
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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
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M O N D AY M A R C H 2N D
, 2 0 1 5
THAN0 YOU;