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8/9/2019 Morning Report Fariz
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MORNING
REPORT
Monday, January 19th2015
Case on : Saturday. January 17th2015
Supervisor
dr. Sabar P. Siregar, Sp. KJ
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PATIENTS IDENTITY
Name : Mrs. W
Age : 44 years old
Gender : femaleAddress : Purworejo, Central Java
Occupation : Unemployed
Marriage status: Widow
Last education: Senior high schoolDate of admission: January 17th2015
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ALLOANAMNESIS
Obtained from
Name : S B
Age : 53 years old 35 years old
Gender : female maleRelationship : Sister Brother
Duration of acquaintance : since birth since birth
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REASON BROUGHT TO THE
HOSPITAL
Patient is brought to the hospital by her family
because she was laughing alone, talking to herself,
talked a lot, talk unfocused, sometimes talk using
english speech, her speech that is not understood,
wandering, unable to sleep, very sensitive, anddifficulty eating.
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PRESENT ILLNESS
The patient began to show the symptoms since 1 years ago after
she was divorce with her husband.
After that, she was talked a lot and change of her attitude and
behavior (hyperactive).
6 months later, her mother was died. And then, her symptoms
increased like talking to herself, talked a lot, and talk unfocused.She did not go to work and her social interaction has been
decreasing since the symptoms appear.
1 Month ago, the symptoms began to get worse. She was laughing
alone, talking to herself, talked a lot, talk unfocused, sometimes
talk using english speech, her speech that is not understood,wandering, unable to sleep, very sensitive, difficulty eating, and
she always heard a voice that is not clear in the midnight after
she was praying.
Concerning with her behavior, her sister and her brother took her
to RSJ Magelang.
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PROGRESSION OF ILLNESS
Talked a lot Change of her attitude and behavior (hyperactive)1 year ago
Talking to herself Talked a lot Talk unfocused Social interaction Productivity
6 months ago
Laughing alone Talking to herself Talked a lot Talk unfocused, sometimes talk usingenglish speech
Speech that is not understood Wandering Unable to sleep Difficulty eating She always heard a voiceVery sensitive Social interaction Productivity
1 monthbefore
admission
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HISTORY OF PRESENT ILLNESS
Psychiatric History
She has neverbeen hospitalizeddue to suchpsychiatrycomplaints
General MedicalHistory
Febrile seizure (-) Epilepsy (-) Trauma (-)
Drugs, alcoholabuse, and smoking
history
Alcoholconsumption (-)
Smoking (-) Drug abuse (-)
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STRESSOR
Divorce
Miss her children
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GENOGRAM
= Patient
= Mental Disorders
= Normal
= Died
= Abortus
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FAMILY HISTORY
Her brother have a history of mental illness
Her brother have medication in RSJ Magelang
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PROGRESSION OF DISORDER
symptom
Rolefunction
The day of
admission1 year ago
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HISTORY OF PERSONAL LIFE
1. Prenatal and perinatal history : Normal (good)
2. Early childhood phase : Good
3. ntermediate childhood : Pass in the !enior "igh school and
continue her study in #aculty of $ussiness and management $ut she didn%t
pass it.&. 'ate childhood : Eer or* in roof company as a secretary manager.
!he as ery disciplin $ecause her father is a military person. "er !piritual is
good.
+. ,dulthood : !he has married and she has & children.
!he as diorce $y her hus$and one year ago $ecause her hus$and haing
an a-air ith another girl. !he is ery sensitie if tal* a$out her hus$and.
"er chidren follo her hus$and and lie far aay from her.
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PERSONAL LIFE
#,'/
Patient is the eleenth daughter of 0fteenth si$lings.
"er father passed aay since she as a child.
"er mother passed aay after she diorce ith her hus$and
"er chidren follo her hus$and and lie far aay from her
,t this moment she lies ith her $rother.
P!/"!E45,' "!6R/
,ppropriate ith her gender. !he reali7es that she is a oman.
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PERSONAL LIFE
!EN "!6R/
edium socioeconomic scale
8,'96/
,lloanamnesis : alid
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MENTAL STATE EXAMINATIONON THE DAY OF ADMISSION (SATURDAY, JANUARY 17TH
2015, 10 AM)
Appearance
, female loo*s suita$le ith her actualage ears complete clothes.
State of Consciousness
lear
Speech uantity: increased
uality : decreased
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Behavior
"ypoactie
Hyperactive
Echopra;ia
atatoniaNegatiism
ataple;y
!tereotypy
annerism
,utomatism
ommandautomatism
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Attitude
Cooperative
ndiferrent,pathy
6ension
9ependentPassie
Active
nfantile
9istrust
'a$ileRigid
Passie negatiism
!tereotipyatalepsy
erea >e;i$ility
E;cited
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EMOTION
Mood "ypothymic Euthymic
Elevated
9ysphoric Euphoria E;pansie
Irritable ,gitation
5nremar*a$le
Affect Appropriate nappropriate Restrictie
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Hallucination
Auditory (+)
lfactory (?) 8isual (?) Gustatory (?)6actile (?)
!omatic (?)
Illusion
,uditory (?)
8isual (?) lfactory (?) Gustatory (?)6actile (?)
!omatic (?)
DISTURBANCE OF PERCEPTION
9epersonalisation (?) 9erealisation (?)
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Quantity
Logorrhea
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ontent of 6houghtIdea of Reference
Preoccupation
Obsession
Phobia
Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hypochondriac
Delusion of magic-mystic
Fantasy
Delusion of Grandiose
Delusion of Control
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Thought of Echo
Thought Insertion
Thought of withdrawal
Thought Broadcasting
Cant be assesed
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#orm of 6hought
Realistic
Non Realistic
Dereistic
Autistic
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!ensorium and ognition
Level of education: good General knowledge: good
Orientation of T/Pl/Pe/S: good/good/good/good Working/short/long memory: good Writing and reading skills: goodAbility to self care: good
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mpulse ontrol @hen E;amined
Self control:Enough Patient response to examiners question:Enough
nsight mpaired
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EXAMINATION
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H!SICAL E"A#I$A%I&$
onsciousnesss: ompos entis
8ital sign:?
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a. "ead: Normocephaly mouth deiation (?) ,nemic conFungtia (?) icteric sclera (?) pupil isocore
$. Nec*: Normal no rigidity no palpa$le lymphnodes
. 6hora;: or : !1 !2 regular murmur ? gallop ? 'ung : 8esicular sound B hee7ing ?B? ronchi ?B?
d. ,$domen:#lat a$dominal allBBchest all normal peristaltictympany sound tenderness ? mass ? lier spleen and*idney not palpa$le
e. E;tremity : @arm acral capillary re0ll H2I edema (?)some $ruises oer el$os and *nees
RE8E@ !/!6E
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ranial neres e;amination:N : in normal 0nding
N : in normal 0nding
N 88 : in normal 0nding
N 8: in normal 0nding
N 8 : in normal 0nding
N 8 : in normal 0nding
N 4 : in normal 0ndingN 4: in normal 0nding
N 4 : in normal 0nding
N 4 : in normal 0nding
NE5RG,' E4,N,6N
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NE5R'G,' !6,65! otori*: Normotonus good coordination of
moement
eningeal sign: negatie
Physiologic re>e; : B
Patologic re>e;: ?B?
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&nset' onth
ago
SI*$IFICA$%FI$I$*S
IFFE,E$%IAL
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IFFE,E$%IALIA*$&SIS
F25.0Schizo-affective Disorders, Manic type
(Skizoafektif tipe manik)
F30.2 Manic with Psychotic Features
(Manik dengan gejala psikotik)
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,;is : #2+.A Schizo-affective Disorders, Manic type
,;is : JA3.2 no diagnosis of a;is
,;is : "ypertension Grade
,;is 8 : 9iorce miss her children
,;is 8 : G,# on admission &A K 31
5'6,4,' 9,GN!!
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1.Problem about patients life (social). 5na$le to hae any normal interaction
. Poor productiity
PR
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2 Problem about patients biological state (biology)
There were imbalance of neurotransmitter.
3.Problem about patients mental state (psychology)
Disturbing towards people surrounding her
She did not control her mood. She always happy and
euforia
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Eergency epartentnF. haloperidol 1 , nF. dia7epam 1 , 8 (sedatie and muscle
rela;ant e-ect)"ospitali7ationris* of damaging herself anddistur$ing people surrounding her
P',NNNG ,N,GEEN6
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%arget %herapy
+AL decrease of symptoms
#aintenance %herapy6a$. 'ithium ar$onat 2AA mg o.12.h.6a$. "aloperidol + mg o.12.h.
6a$. ,mlodipin 1;1Amg
,ES&$SE HASE
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6arget therapy:
? 1AAL remission of symptoms
npatient management:
? ontinuing the pharmacotherapy:
6a$. "aloperidol + mg o.12.h6a$. 'ithium car$onat 2AA mg o.12.h6a$. ,mlodipin 1;1Amg? mproing the patient Muality of life:
6eaching patient a$out her social enironment
(interacting ith her family sociali7ing ith herneigh$or or friends 0nding a ho$$y to do on herspare time)
utpatient management:
? Pharmacotherapy
REMISSION PHASE
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ontinuing the medication control topsychiatric
Reha$ilitation: "elping patient to interact normally ith her family
friends and neigh$or
9oing some actiities that can *eep patient feeloccupied
RECOVERY PHASE
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THANKYOU
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