Morning Repffhgfghfhgfghort Hahah

8/17/2019 Morning Repffhgfghfhgfghort Hahah

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Case presentationRSJ Prof. Dr. Soerojo


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Patient’s Identity

1. Name : Tn. M2. Date of birt : jan!ary" 12t 1#$2

%. Re&i'ion : Mos&em(. )ddress : Seday! I RT *% R+ 1%M!nti&an

,. Job : Stone -reaer

/. Marita& stat!s : !nmarried0. tniity : ja3anesse$. d!ationa& stat!s : 'rad!ated from

J!nior 4i' soo&


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)&&oanamnesis 5as

ond!ted to : Name : Saro5i

Job : Merant

Re&ation : 6ater

)ddress : Seday! I RT *% R+ 1% M!nti&an


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Psychiatrichistory

Mornin' Report

Sat!rday" 7tober 2,t" 2*1(


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Cief Comp&aint

)n'ry" treaten peop&e and patients 5ant to itpeop&e from one 5ee a'o


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Stressor


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History of Present

Illness

3 months ago, his seizure is very disturbing sohe decide to go to the hospital. He get the medicationbut he just consumed it for a month because hethought that the medication is unsuccesfull so he

stoped it.

16 years ago, after after patients graduatesfrom junior high school he is looing for a job. He tellsthat if he get tired he started to seizure and he tellsthat !hen he get it he is unconcious and feeling

nothing. Patients and his parent go to the hospital.He still get seizure after the medication so hedecide to stop the medication of his seizure.


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"ont..

Patients feeling angry and threathen otherpeople. He heard animal voice such lie chicen evenin that time there is no cho#icen around of patients.He felt very confuse and angry, so he e$press his

confuseness !ith angry and threathen other people.

He said that he can%t sleep because of hishalucination of sound and he also said that he can%tsleep !ell. He also feels that his body is loced !hen

he !ant to pray, he can%t open his mouth. &hen itshappen a !hole of his body is feel cold and he feelsuncomfort.

He said that if he get his seizure there !as

something that as him to sucide or ill him self buthe don%t reall care about it. 'ometimes that sound


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Cont..

Psyiatri i&&ness 4e ne3er ad a psyiatri prob&e before

8enera& media& i&&ness

4istory i&&ness.

4ead tra!ma 9;" pi&epsy 9sine 1/ years a'o;

Diabetes Me&&it!s 9;

4ypertension 9;

Ma&aria 9;

S!bstane ab!se

4istory of smoin' 92% i'arette a day;

N)P


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6ami&y 4istory

Tere is no one of patient fami&ytat a3e psyiatri prob&em

pi&epsi 9;

4ypertension 9;

Diabetes Me&&it!s 9;


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4istory of Persona& >ife

Prenata& ? Perinata&4istory of pre'nany

Patients is te %rd i&d from fo!r i&dren. Teprenany 5as p&anned and tere is no prob&em d!rin'te pre'nany.

4istory of birt

4e 5as born norma&&y at ome 5it te e&p from

traditiona& mid5ife.


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()*+ "HI+-H- PH)'(()*+ "HI+-H- PH)'(

/03 ()*' +-2/03 ()*' +-2

Patients 'ro5s norma&&y. Tere is no data 5itde3e&opment pro'ress at tis time. Tere is no 3a&iddata 5en patients @rst time ra5&in'" sittin'"standin' and ro&&in' o3er.


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I4(*5(-I)4(I4(*5(-I)4( "HI+-H-"HI+-H-

PH)'( /PH)'( /311311 ()*' +-2 ()*' +-2

Patients 'ro5 and de3e&opment norma&&y.Patient an p&ay and omm!niate 5it oteri&dren norma&&y. Patients &ie 'ymnasti andsoer. 4e &ies to p&ay 5it oter i&dren afterba to soo&. Patients 'rad!ate frome&ementary soo& at siAt 'rade. Patientsontin!e is ed!ation at j!nior i' soo&.


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>)T C4I>477D ? TN)8>)T C4I>477D ? TN)8

P4)SP4)SPatient 'rad!ates from j!nior i' soo& andpatient an’t ontin!e is ed!ation bea!se &aof money. So e deide to &oo for job. Patient anomm!niate 5it te nei'boor. Patients rea&iBe

tat e is a ma&e 5o interest 5it fema&e


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)-+4H-


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History of Personal +ife

• Patient rea&iBe tat e is a ma&eand patient interest 5it fema&e


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8eno'ram


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Pro'ression of I&&ness

Symptoms

Role

Function


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(7)5I)4IMornin' Report

Sat!rday" 7tober 2,t" 2*1(


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Physical ($amination

8enera& pysia& eAamination 8enera& appearane : ompos

mentis ita& si'n :

-P : 12*#*

4R : $*to : 2*

RR : %/"2

Sat!rday" 7tober 2,t" 2*


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Re3ie5 System

4ead : normoepa&i" mo!t de3iation 9; anemi onj!n'ti3a 9;" iteri s&era 9;" p!pi&

isoore Ne : no ri'idity" no pa&pab&e &ymp nodes 9 ; ToraA :

Cor : S1 S2 re'!&ar" m!rm!r 9;" 'a&&op 9; >!n' : 3esi!&ar so!nd == " 5eeBin' "

roni )bdomen :

6&at abdomina& 5a&&est 5a&&" norma&perista&ti" tympany so!nd" tenderness 9;" mass9;" pa&pab&e &i3er" sp&een and idney 9;

Atremity : +arm ara&" app re@&& E2s" edema 9;


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eurogical ($amination

Crania& ner3es eAamination:

CN I : norma&

CN II : norma&

CN III"I"I : norma&

CN : norma&

CN II : norma&

CN III : norma&

CN IF : norma&

CN F : norma&

CN FI : norma&

CN FII : norma&


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Cont..

Pysio&o'ia& reGeA

Hpper eAtremities: bieps reGeA 9=;" trieps reGeA 9=;

>o5er eAtremities: pate&&a reGeA 9=;" ai&&es tendon reGeA 9=;

Pato&o'ia& reGeA

Hpper eAtremities: 4oman 9;" Tromner 9;

>o5er eAtremities: babinsi 9;" addo 9;" 'ordon 9;" oppeneim 9;


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5ental 'tate

($amination )ppearance8

Patient rea&iBe tat e is a ma&e 5o

interest by fema&e.

'tate of consciousness8 &ear

'peech8 !antity : remmin'

!a&ity : derease

Sat!rday" 7tober 2,t"

2*1(


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Cont..9(H):I*


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Cont..)44I4-(


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Cont..

M77D )66CT

-ysphoric

!tymi&e3ated!poriaApansi3e

Irritab&e)'itationCan’t be assesed

)ppropriate

InappropriateRestriti3e-&!nted6&at

>abi&e

(54I


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Cont..

4a&&!ination I&&!sion

)!ditory 9=;

is!a& 9;7&fatory 9;8!statory 9; Tati&e 9;

Somati 9;

)!ditory 9;

is!a& 9;7&fatory 9;8!statory 9; Tati&e 9;

Somati 9;Depersona&iBation 9; Derea&iBation 9;

-isturbance of

Perception


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Cont..

!antity !a&ity

>o'orrea-&oin'

*emmingM!tism

Ta&ati3e

CoerentIrrelevant ans!erCopro&a&iaIncoherence6&i't of ideaPo3erty of speeConfab!&ation>oosenin' of assoiationNeo&o'ismeCir!mtansia&ity Tan'entia&erbi'erationPerse3erationSo!nd assoiation+ord sa&ado&a&ia

4hought

Progression


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Cont..

• De&!sion of 8randiose

• De&!sion of Contro&

• De&!sion of Re&i'ion

•De&!sion of InG!ene

• De&!sion of Passi3ity

• De&!sion of Pereption

• De&!sion of S!spiion

• To!'t of o

• To!'t of Insertion ?5itdra5a&

• To!'t of -roadastin'

• Idea of *eference• Idea of 'randiose• Preoccupation• 7bsession• Pobia• 6antasy• De&!sion of Perse!tion• De&!sion of Referene•

De&!sion of n3io!s• De&!sion of4ypoondria

• De&!sion of Ma'imysti

"ontent of

4hought


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Cont..6orm of To!'t


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'ensorium and

"ognition >e3e& of ed!ation : j!nior 4i' soo&

8enera& no5&ed'e : 'ood

7rientation of time : 'ood

7rientations of p&ae : 'ood 7rientations of peop&e : 'ood

7rientations of sit!ation : 'ood

+orin'sort&on' memory : 'ood

+ritin' and readin' si&&s : 'ood

is!ospatia& : 'ood )bstrat tinin' : 'ood

)bi&ity to se&f are : 'ood


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Impulse control !hen

e$amined Se&f ontro&: 'ood

Patient response toeAaminers K!estion: 'ood


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Insight

Impaired insight

Inte&&et!a& Insi't Tr!e Insi't


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*('5(Mornin' Report

Sat!rday" 7tober 2,st" 2*1(

) man, ;3 years old, married, employed, easily getting angry,


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, y , , p y , y g g g y,threatens others, change in behavior, irritable, suspicious

'ymptom8 5ental 'tatus8 Impairment8

• -ea3ior:• )tit!de :• Mood :• )et :

• Pro'ression of To!'t:

• Content of to!'t:

• 6orm of to!'t :

• Pereption :


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-I)


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'yndrome

'yndrome

'yndrome


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-i=erential -iagnosis


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5ultia$ial -iagnosis

)Ais I :

)Ais II :

)Ais III :

)Ais I :

)Ais :


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5))


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5anagement Planning

4ospita&iBed

Parmaoterapy

Psyoed!ation


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*esponse Phase

Tar'et terapy :,*L derease of symptoms

Maintenane

Reassess patient


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*ecovery Phase

Contin!e te mediation"ontro& to psyiatri

Reabi&itation :


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4han ou> Sat!rday" Mar 21st 2*1,

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Morning Repffhgfghfhgfghort Hahah