morport ABK2

8/19/2019 morport ABK2

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SUPERVISOR

dr. Sabar P. Siregar, Sp.KJ

*MORNING REPORT

Thursday afternoon, 02 January 2014


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I. PATIENT’S IDENTITY

AutoanamnesisName : Mr. HAge : 29 years oldender : Male

Address : Tegal!""u#ation : Dri$erMarital status : single%ast edu"ation : Elementary S"&oolAlloanamnesisName : Mr. 'Age : () years old*elation : &is un"le


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*Pre"ent Hi"t%ry

Poor utilization of leisure time

poor grooming

Poor utilization of leisure time

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

& 'ee( ag%

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


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• Patient has been hospitalized fourthtime in RSS !agelangPsychiatryhistory

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

)eneralmedical history

• *rugs consumption "#$• (lcohol consumption "#$• &igarette Smoking "+$

*rugs andalcohol abusehistory and

smoking history


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*EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Psychomotoric (UNVALID DATA)

• T&ere -ere not get im#ortant data on #atients gro-t& and de$elo#ment su"& as:• rst time li/ting t&e &ead 013 mont&s4• rolling o$er 013 mont&s4• Sitting 039 mont&s4• 5ra-ling 039 mont&s4• Standing 039 mont&s4• -al6ingrunning 0972 mont&s4• &olding o8e"ts in &is &and013 mont&s4

• #utting e$eryt&ing in &is mout&013 mont&s4Psychosocial (UNVALID DATA)• T&ere -ere not get im#ortant data on -&i"& age #atient

• started smiling -&en seeing anot&ers /a"e 013 mont&s4• startled 8y noises013 mont&s4• -&en t&e #atient rst laug& or suirm -&en as6ed to #lay; nor #laying "la#s -it& ot&ers

039 mont&s4

Communication (UNVALID DATA)

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


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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- ealousy 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- o8e"ts; re"ogni


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*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 ealously 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.


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*ADULTHOOD

E!ucational $istory Elementary S"&ool

%ccu"ational history Dri$er and no- not -or6

&arital Status

singleCriminal $istory

No

Social Activity Patient ha! introvert "ersonality' an! he ha! a goo! relationshi" ith his

neighour*Current Situation He li$es -it& &is /amily


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* Eri("%n*" "tage" %$ p"y+%"%+ia#dee#%p!ent

Stage -a"i+ %n$#i+t I!p%rtant Eent"

2nfancy"birth to ,3 months$

4rust 's mistrust 5eeding

Early childhood"6#7 years$

(utonomy 's shame and doubt 4oilet training

Preschool"7#8 years$

2nitiati'e 's guilt E9ploration

School age"0#,, years$

2ndustry 's inferiority School

(dolescence

",6#,3 years$

2dentity 's role confusion Social relationships

/%ung Adu#t%%d012345 year"6

Inti!a+y " i"%#ati%n Re#ati%n"ip

!iddle adulthood":;#08 years$

)enerati'ity 's stagnation Work and parenthood

!aturity"08# death$

Ego integrity 's despair Reflection on life


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*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


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

*He attra"ted a -omen 8ut &e did not dareto "on/ess.


14/37

*G%#'$am


15/37

Socio#economic history

• Economic scale < no data

=alidity

• (lloanamnesis < 'alid• (utoanamnesis < un'alid


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

Sym*"#m

R#l% +,"i#

&514&511 &51&


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18/37


19/37


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Emotion

!ood

• Dys#&ori" 0@4• Ele$ated• Eu#&oria• E=#ansi$e• Irrita8le• Agitation• 5an’t 8e

assessed

(ffect

• A##ro#riate• Ina##ro#riate 0@4• *estri"ti$e• +lunted

• Blat• %a8ile


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Distur8an"e o/ #er"e#tion

Ha##u+inati%n

• (uditory "#$• =isual "#$• @lfactory "#$• )ustatory "#$

• 4actile "#$• Somatic "#$

I##u"i%n

• (uditory "#$• =isual "#$• @lfactory "#$• )ustatory "#$

• 4actile "#$• Somatic "#$

*epersonalisation "#$ *erealisation "#$


22/37

T&oug&t #rogression

8uantity

• Logorrhea• Blocking

• Remming• !utisme• 4alk acti'e "+$

8ua#ity

• 2rrele'an answer• 2ncoherence• 5light of idea

• @'er#'alued idea• &onfabulation• Po'erty of speech• Loosening of association• Aeologisme

• &ircumtansiality• =erbigrasi• Perse'erasi• Sound association• Word salad

• Echolalia


23/37

5ontent o/ t&oug&t

2dea of Reference

Preoccupation

@bsession

Phobia*elusion of Persecution

*elusion of Reference

*elusion of En'ious*elusion of Hipochondry

*elusion of magic#mystic "+$

*elusion of grandiose "+$

*elusion of &ontrol

*elusion of 2nfluence

*elusion of Passi'ity

*elusion of Perception

4hought of Echo

4hought of 2nsertion "+$

4hought of Broadcasting


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Borm o/ T&oug&t

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


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

%e$el o/ edu"ation : Senior &ig& s"&ool eneral 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 : 8ad


26/37

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

• Self control< enough• Patient response to

e9aminers uestion


27/37

I"%$al S"a"+!

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

◦ +lood #ressure : 72?C>? mmHg

◦ Pulse rate : >? =Cmnt

◦ Tem#erature : a/e8ris

◦ ** : 2?=Cmnt


28/37

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<


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

*!otoric< Aormotonus> good coordination of

mo'ement

*Physiological refle9<Biceps +C+> 4riceps +C+> DPR +C+

*Pathological refle9<

Hoffman#4romer #C#> Babinski #C#>

&haddock #C#>

RES!E


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RES!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'e2nappropiate

4hought insertion

*elution of grandious

*elution of magic

mistic

Aon Frealistic

2mpaired insight


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Dierential Diagnose

• 568/6 Schizoaffecti'e mi9ed type

• 57,/6 Bipolar affecti'e

disorder>present manic episode with

psychotic symptoms


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M+l"ia5ial Dia'#!%

(9is 2 < 568/6 Schizoaffecti'e mi9ed type

(9is 22 < R:0/3 delayed diagnosis of a9is 22

(9is 222 < Ao diagnose

(9is 2= < Psychosocial and en'ironmental problems(9is = < )(5 admission 6;#,,


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* Terapy

Hospitalization

#ur#ose o/ &os#itali


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*PLANNING MANAGEMENT

P&arma"ot&isa#y

! Emergen"y t&era#y

! In. Halo#eridol (mg 7 am#ul im

!*outine t&era#y!Halo#eridol 2 = ( mg!%itium 6ar8onat 7 = )?? mg


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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.

* Hel# t&e #atient -&en s&e needs it.

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

"ommuni"ation and understanding.


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*PROGNOSIS

(d 'itam < ad bonam

(d functionum < dubia ad malam

(d sanationum < dubia ad malam


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Ta Y#+=

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