morport ABK2 2

8/19/2019 morport ABK2 2

1/38

SUPERVISOR

dr. Sabar P. Siregar, Sp.KJ

*MORNING REPORT

Thursday afternoon, 02 January 2014


2/38

I. PATIENT’S IDENTITY

AutoanamnesisName : Mr. YAge : 30 years oldGender : Male

Address : Pemalang!!u"ation : Ele!tri!ianMarital status : #ido#er$ast edu!ation : Senior %ig& S!&oolAlloanamnesisName : Mrs. YAge : '( years old)elation : &is sister


3/38

)EASN *%Y PATIENT+),G%T T %SPITA$

Angry and Hurt i!"e#$


4/38

*Pre"ent Hi"t%ry

Poor utilization of leisure time

poor grooming


poor grooming

EasilyThe

& !%nt ag% & 'ee(" ag%


5/38

*Pre"ent Hi"t%ry


poor grooming


poor grooming

Easily get angry

Broke his furniture at home and hisgrand mother house

He was Wandering and could not goback home

He refused to work

Hurt himself and start to burn his

hairLaugh his own self

) day" ag%

*ay %$ad!i""i%n


6/38

• Patient has been hospitalized fourthtime in R! "agelangPsychiatryhistory

• Hypertension #$%• Head in&ury #$%• 'on(ulsion #$%• )sthma #$%• )llergy #$%

*eneralmedical history

• +rugs consumption #$%• )lcohol consumption #$%• 'igarette moking #,%

+rugs andalcohol abusehistory and

smoking history


7/38

*EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Psychomotoric (UNVALID DATA)

• T&ere #ere not get im"ortant data on "atients gro#t& and de-elo"ment su!& as:• rst time li/ting t&e &ead 312 mont&s• rolling o-er 312 mont&s• Sitting 214 mont&s• 5ra#ling 214 mont&s• Standing 214 mont&s• #al6ing1running 417' mont&s• &olding o89e!ts in &is &and312 mont&s

• "utting e-eryt&ing in &is mout&312 mont&sPsychosocial (UNVALID DATA)• T&ere #ere not get im"ortant data on #&i!& age "atient

• started smiling #&en seeing anot&ers /a!e 312 mont&s• startled 8y noises312 mont&s• #&en t&e "atient rst laug& or suirm #&en as6ed to "lay; nor "laying !la"s #it& ot&ers

214 mont&s

Communication (UNVALID DATA)

• T&ere #ere not get im"ortant data on #&en patient started saying words - year like .mom/or .dad/0 #1$2 months%


8/38

Emotion (UNVALID DATA) T&ere #ere not get im"ortant data o/ "atient’s rea!tion

#&en "laying; /rig&tened 8y strangers; #&en starting tos&o# 9ealousy or !om"etiti-eness to#ards ot&ers and toilettraining.

Cognitive (UNVALID DATA) T&ere #ere not get im"ortant data on #&i!& age t&e

"atient !an /ollo# o89e!ts; re!ogni


9/38

* INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor (UNVALID DATA)

not get im"ortant data on #&en "atient’s rst time riding a8i!y!le; i/ "atient e-er in-ol-ed in any 6ind o/ s"orts.

Psychosocial (UNVALID DATA)

not get im"ortant data on "atient intera!tion #it& &is

surrounding; not get im"ortant data on #&en "atient rstentered "rimary s!&ool; &o# #ell &e "lay #it& &is ne# /riend onrst day s!&ool.

Communication (UNVALID DATA)

not get im"ortant data regarding "atient a8ility to ma6e /riends

at s!&ool and &o# many /riends "atient &a-e during &is s!&ool"eriod

Emotional (UNVALID DATA)

not get im"ortant data on "atient’s ada"tation under stress;any in!idents o/ 8ed#etting #ere not 6no#n.

Cognitive (UNVALID DATA )


10/38

*LATE CHILDHOOD & TEENAGE PHASE

Seual !evelo"ment signs # activity (UNVALID DATA) No data on #&en "atient e="erien!e #et dream; &air on

arm"its and "u8is; et!

* Psychomotor (UNVALID DATA)

No data i/ "atient &ad any /a-ourite &o88ies or games; i/ "atient

in-ol-ed in any 6ind o/ s"orts.* Psychosocial (UNVALID DATA)

Patient &ad ne-er 8een told /amily a8out "atient’s /riend.

* Emotional (UNVALID DATA)

not get im"ortant data on "atients rea!tion on "laying; s!ared;

s&o#ed 9ealously or !om"etiti-eness* Communication (UNVALID DATA)

not get im"ortant data on &o# #ell t&e relations&i" 8et#een"atient #it& "arent and &is /amily.


11/38

*ADULTHOOD

E!ucational $istory Senior %ig& S!&ool

%ccu"ational history Ele!tri!ian

&arital Status

marriedCriminal $istory

No

Social Activity Patient ha! introvert "ersonality' an! he ha! a social ith!raal

Current Situation %e li-es #it& &is mot&er.


12/38

* Eri("%n+" "tage" %$ p"y%"%ia#de-e#%p!ent

Stage a"i /%n$#it I!p%rtant E-ent"

3nfancy#birth to -4 months%

Trust (s mistrust 5eeding

Early childhood#6$7 years%

)utonomy (s shame and doubt Toilet training

Preschool#7$8 years%

3nitiati(e (s guilt E9ploration

chool age#1$-- years%

3ndustry (s inferiority chool

)dolescence

#-6$-4 years%

3dentity (s role confusion ocial relationships

0%ung Adu#t%%d1&2345 year"6

Inti!ay -" i"%#ati%n Re#ati%n"ip

"iddle adulthood#:;$18 years%

*enerati(ity (s stagnation Work and parenthood

"aturity#18$ death%

Ego integrity (s despair Reflection on life


13/38

*Familyi!"#$y

*Patient is t&e se!ond !&ild o/ > si8lings.

* T&ere’s no "sy!&iatry &istory in t&e/amily.

Family i!"#$y


14/38

*P"y%"e7ua# Hi"t%ry

*%e’s 8een married and &a-e 7 !&ildren ;and no# &e’s di-or!e


15/38

*G%#'$am


16/38

ocio$economic history

• Economic scale < no data

=alidity

• )lloanamnesis < (alid• )utoanamnesis < un(alid


17/38

*P$#'$%!!i# # i!#$%$

Sym*"#m

R#l% +,"i#

)5&8)5&& )5&)


18/38

Mental StateSaturday a/ternoon; 77t& ?anuary '07>

Appearane

• Look a man> appropriate to his age> completely

clothed

State %$ /%n"i%u"ne""

• 'lear

Spee

• ?uantity < 3ncreased• ?uality < +ecreased


19/38

%a.i#+$

%y"oa!ti-e%y"era!ti-eE!&o"ra=ia

5atatonia A!ti-e negati-ism5ata"le=yStrereoty"y

MannerismAutomatism

5ommand automatismMutismA!at&ysia

Ti!Somna8ulismPsy!&omotor agitation5om"ulsi-eAta=iaMimi!ryAggresi-eIm"ulsi-eA8ulia


20/38

ATTITUDE

C##*%$a"i.%Non1

!oo"erati-e Indi/errentA"at&y Tension

De"endentA!ti-e Passi-e

In/antileDistrust$a8ile

)igidPassi-e negati-ism5atale"sy5erea @e=i8ility

E=!itement


21/38

Emotion

"ood

• Dys"&ori! • Ele-ated• Eu"&oria• E="ansi-e• Irrita8le• Agitation• 5an’t 8e

assessed

)ffect

• A""ro"riate• Ina""ro"riate • )estri!ti-e• +lunted

• Blat• $a8ile


22/38

Distur8an!e o/ "er!e"tion

Ha##uinati%n

• )uditory #$%• =isual #$%• @lfactory #$%• *ustatory #$%

• Tactile #$%• omatic #$%

I##u"i%n

• )uditory #$%• =isual #$%• @lfactory #$%• *ustatory #$%

• Tactile #$%• omatic #$%

+epersonalisation #$% +erealisation #$%


23/38

T&oug&t "rogression

9uantity

• Logorrhea• Blocking

• Remming• "utisme• Talk acti(e #,%

9ua#ity

• 3rrele(an answer• 3ncoherence• 5light of idea

• @(er$(alued idea• 'onfabulation• Po(erty of speech• Loosening of association• Aeologisme

• 'ircumtansiality• =erbigrasi• Perse(erasi• ound association• Word salad

• Echolalia


24/38

5ontent o/ t&oug&t

3dea of Reference

Preoccupation

@bsession

Phobia+elusion of Persecution

+elusion of Reference

+elusion of En(ious+elusion of Hipochondry

+elusion of magic$mystic

*e#u"i%n %$ grandi%"e

+elusion of 'ontrol

+elusion of 3nfluence

+elusion of Passi(ity

+elusion of Perception

Thought of Echo

Thought of 3nsertion

Thought of Broadcasting


25/38

Borm o/ T&oug&t

)ealisti!N# R%ali!"i,Dereisti!Autisti!


26/38

S%!#$i+m a C#'i"i#

$e-el o/ edu!ation : ?unior &ig& s!&ool General 6no#ledge : enoug& rientation o/ timeC"la!eC"eo"leCsituation:

goodCgoodCgoodCgood *or6ingCs&ortClong memory : good *riting and reading s6ills : not e=amined isuos"atial : not e=amined A8stra!t t&in6ing : not e=amined A8ility to sel/ !are : enoug&


27/38

I!pu#"e %ntr%# 'ene7a!ined

• elf control< enough• Patient response to

e9aminers uestion


28/38

I"%$al S"a"+!

5on!iousnes : !om"os mentisital sign :

◦ +lood "ressure : 70C700 mm%g

◦ Pulse rate : F0 =Cmnt

◦ Tem"erature : a/e8ris

◦ )) : '0=Cmnt


29/38

H%a / #$m#,%*ali

Ey%! / a%mi, ,#+'"i.a --2 i,"%$i, !,l%$a --2

*+*il i!#,#$%

N%, / #$mal2 # $i'ii"y2 # *al*a4l% lym* #%!

T#$a5/

C#$ / S 126 S#+ a #$mal

L+' / .%!i,+la$ !#+2 7%%8i' --2 $#,i--

A4#m% / Pai (-) 2 #$mal *%$i!"al"i,2 "ym*ay

!#+

E5"$%mi"y / 9a$m a,$al2 ,a** $%:ll ;6<


30/38

*N%+$#l#'i,al %5am /

*"otoric< Aormotonus> good coordination of

mo(ement

*Physiological refle9<Biceps ,C,> Triceps ,C,> DPR ,C,

*Pathological refle9<

Hoffman$Tromer $C$> Babinski $C$>

'haddock $C$>

RE"E


31/38

RE"E

Sy!pt%!"

Easily get angry

Laugh his own self

Broke his furniture athome and his grand

mother house

He was Wandering and

could not go back home

He refused to work

Hurt himself and start

to burn his hair

Laugh his own self

I!pair!ent

Poor utilizationof leisure time

Poor grooming

Menta#Statu"

cooperati(e3nappropiate

Thought insertion

+elution of grandious

+elution of magic

mistic

Aon Frealistic

3mpaired insight


32/38

Dierential Diagnose


33/38

M+l"ia5ial Dia'#!%

)9is 3 <

)9is 33 <

)9is 333 <

)9is 3= <)9is = <


34/38

* Terapy

Hospitalization

"ur"ose o/ &os"itali


35/38

*PLANNING MANAGEMENT

P&arma!ot&isa"y

Emergen!y t&era"y

in9. %alo"eridol mg im In9. Dia


36/38

P!y,#-%+,a"i#

Edu!ate t&e "atient and /amily a/ter medi!ation:

*E="lain to "atient’s /amily a8out mentaldisorder. T&ere are many /a!tors !ause t&esym"toms.

* Treat t&e "atient a!!ording to t&e /amily’sa8ility; don’t demand t&e "atient more nor less.

* %el" t&e "atient #&en s&e needs it.

* Edu!ation o/ t&e /amily to en!ourage

!ommuni!ation and understanding.


37/38

*PROGNOSIS

)d (itam < ad bonam

)d functionum < dubia ad malam

)d sanationum < dubia ad malam


38/38

Ta Y#+=

Documents

morport ABK2 2