morpot umy-unisula (2)

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    Morning reportTuesday, 08-05-2012

    Supervisor : dr. Sabar P. Siregar,Sp.Kj

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    Patient identity

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    Alloanamnesis

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    Chief complaint

    Patient talked alone + 3months before admission

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    History of PresentIllness

    1 week

    before

    admission

    3 months

    before

    admission

    Patient talked to him selfEasily irritatedLoss of appetiteSleeping disturbanceLike being alonePatient thought that he saw a shadow, and hearthat someone called him.

    Patient felt that someone chasing himDisturbing his friend

    Patient talked to him selfLoss of appetiteSleep disturbance (initial insomnia)Liked being alonePatient thought that his friend would liketo do harmEasily irritatedPatient thought that he saw a shadow,

    and hear that someone called him

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    Previous History of Disease

    MEDICALHISTORY

    DRUGSHISTORY

    PSYCHIATRYHISTORY

    Havent been hospitalizedbefore

    DM(-) Hypertension(-)Asthma(-)Alergy (-) Seizure history (-)

    Drugs History (-)Alchoholic (-)Smoking (-)

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    History of personal life

    Prenataland

    PerinatalHistory

    No Data

    Early

    ChildhoodPhase

    No Data

    Intermediate

    ChildhoodPhase

    Patient finished elementaryschool at 12 y.o, but havent

    passed the examination.Late

    ChildhoodPhase

    Patient entered Junior HighSchool at 14 y.o after gettingPaket B.

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    AdulthoodPhase

    Education : Junior High SchoolOccupation : UnemployedReligion : praying frequently, 5

    times/dayMilitary : No dataPsikosexual : Patient performand behave like a man,attracted to women.

    Frequentlymasturbated, twice a dayCriminal : No data

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    Genogram

    Patient

    NormalWoman

    NormalMan

    Suicide

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    Family History :Patient is the third child from 6 siblings.His younger brother was suicide. His

    father is unemployed, and always prayall day long.

    Sosioeconomic History :

    Patient is unemployedPatients mother is the main support ofhis family economic lifeSocial interaction is limited

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    Level of convidence

    Alloanamnesis : untrustable

    Autoanamnesis : trusted

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    Illness progression

    symptom

    Role

    function

    3monthsbeforeadmissi

    on

    1 weekbeforeadmissi

    on

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    A. GENERAL DESCRIPTION

    1.

    APPEARANCEA man, looked like his age

    He wore a black trousers with white shirt

    He has black hair and his body postureis astenicus

    2. Psychiatry Conciousness

    Mental State

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    3. behavior

    normoactive

    Hypoactive

    Hyperactive

    Echoplaxia

    Catatonia

    Active negativisme

    Catoplexi

    Streotype

    Mannerism

    Otomatism

    q Command otomatismq Acathysiaq Ticq Sonambulismq Psychomotor

    agitationq Compulsiveq Ataxiaq Mimicryq Aggresiveq Impulsiveq Abulia

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    4. attitude

    CooperativeNon-cooperative

    Indiferrent ApathyTention Dependent Active

    Passive

    Infantile Distrust Labil

    Rigid Passive negativism Streotype Catalepsi Cerea flexibility

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    5. Psychis contact

    easily drawn, easyto be specified

    hardly drawn, easy to bespecified

    hard drawn, hard to bespecified

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    B. EMOTION

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    C. PERCEPTION DISORDER

    Depersonalitation :

    -

    Dereliasitation: -

    Halucination

    AuditoryVisualOlfactoryGustatoryTactileSomatic

    Illusion

    AuditoriyVisualOlfactoryGustatory

    Tactile

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    D. Thought process

    1. Thought progression

    QUANTITY Logorrea

    Remming Blocking Mutisme Talkactive

    QUALITY

    coherenceIncoherence

    Flight of idea Circumstansiality Poverty of speech

    neologismTangensiality Verbigrasi Perseverasi Convabulation Ecolali

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    2. Thought content

    Idea of reference Preoccupation Obsession Phobia Delusion of suspicious Delusion of envious

    Delusion of

    persecutory Grandious Delusion

    Delusion ofmagic-mistic

    Delusion of control Delusion of influence Delusion of passivity Delusion of perceptionThought of echo

    Thought ofinsertion/withdrawal

    Thought of broadcasting

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    4. Sensorium & cognition

    Educational : lack of educational

    Knowledge : good

    Orientation w/t/o/s :good/good/good/good

    immediate memory/short/long :good/good/good/good

    ability to read and write : good

    Visuospatial ability : cant be evaluated

    Abstract thought : can`t be evaluated

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    Si ifi Fi di

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    Significant FindingResume

    A man, 22 years old, unemployed

    Talk to himself

    Like being alone, got sleep disturbance(initial insomnia), loss of appetite,easily irritated.

    Attitude : cooperative, behavior :normoactive

    Mood : dysforic, Affec : appropiate,restrictive

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    Deterioration :

    role function : poor Social function : poor

    Sparetime managemet : poor

    self care : enough

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    Differential Diagnosis

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    Multiaxial diagnosis

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    Hospitalized

    - Explain to his family about the mental disorder ofthis patient include the causes.

    - Describes steps of treatment-family must maintain the patients drugs consumptionand routine doctor consultation , so it will increase theefficacy of treatment-familiy must keep in touch with patient intensively, sothe patient will not feel lonely- the family shouldnt force the patient to think like a

    Farmacotherapy : Haloperidol tab 2x5 mg/day

    Family education:

    TREATMENT

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    Prognosis

    Ad vitam : dubia ad malam

    Ad Sanationum : dubia ad malam

    Ad Fungsionum : dubia ad malam

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