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SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ
MORNING REPORTFriday, May 9th 2014
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Patient IdentityAutoanamnesis Name : Sex : Age : years old Address : Occupation : Marital State :
Alloanamnesis Name : Sex : Relation :
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Reason patient was brought to
emergency room
Patient refuse to take his medicine andshowing weird behavior
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Stressor
Meeting his wife and childrenwho didnt live in the same house
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Past HistoryPatient has history of hospitalization at 2003, 2009,2 times at 2010, 2013, and March 2014.
He usually brought to hospital because of goingmad, refusing to take his medicine, wanderingaround, and disturbing his neighbours.He started showing symptoms around 2003because he was fired from his job in Jakarta. Andstarted living separately from his wife and children.His smoking habit became more frequent whenhes about to relapse.
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Day of Admission
9th May 2014
Patient brought with thecomplaints of:
Didnt take his medicine Refused going to hospital for
routine control Giving his wares to other people
without any reason
Brought to hospitalby his mother
He worked as a merchantPoor utilization of leisure time
He could nt socialize with friendsThe patient didnt take any medicine
for 4 days
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Generalmedical history
Head injury (-) Hypertension (-) Convulsion (-) Asthma (-) Allergy (-)
Drugs and alcoholabuse history andsmoking history
Drugs consumption (-) Alcohol consumption (-) Cigarette Smoking (+) - frequencyincreased when symptoms worsened
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ADULTHOODEducational History He finished junior highschool
Occupational historyHe started to work inJakarta when he was 15 yrold. His mother didnt know anything about hisoccupation.
Marital StatusMarried, but not living inthe same house
Criminal HistoryNo
Social Activity
Before he was sick, he wasa friendly guy and hadmany friends
Current SituationHe lives with his parents,
he has no friends. And heworks as a merchant
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FAMILY HISTORY
Patient is the 2nd child of 4 siblings
Psychiatry history in the family his youngersister also has same symptom
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GENOGRAM
Pria Wanita Pasien Meninggal
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PSYCHOSEXUAL HISTORY
Patient realizes that he is a male, and interested infemale. His attitude is appropriate as a male.
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Socio-economic history Economic scale : low
Validity
Alloanamnesis: valid Autoanamnesis: valid
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Progression of Disorder
Symptom
Role Function
2003 2013 20142009 2010 2010
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Appearance A male, appropriate to his age, completely clothed,
nicely groomed
State of Consciousness Clear
Speech Quantity : Increased Quality : Decreased
Mental State May 9 th 2014
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BEHAVIOUR
Hypoactive Hyperactive Echopraxia
Catatonia Active negativism Cataplexy Streotypy Mannerism Automatism Bizzare
Command automatism Mutism Acathysia Tic Somnabulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia
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ATTITUDE
Non-cooperative Indiferrent Apathy Tension Dependent Passive
Infantile Distrust Labile
Rigid Passive negativism Stereotypy Catalepsy
Cerea flexibility Excited Stable
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Emotion
Mood
Dysphoric Euthymic Elevated Euphoria
Expansive Irritable Agitation Cant be assesed
Affect
Appropriate Inappropriate Broad Restrictive Blunted Flat Stable Labile
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Disturbance of Perception
Hallucination
Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-)
Illusion
Auditory (-) Visual (-) Olfactory (-) Gustatory (+) Tactile (-) Somatic (-)
Depersonalization (-) Derealization (-)
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Thought Progression
Quantity
Logorrhea Blocking Remming Mutism
Talkative
Quality
Irrelevant answer
Incoherence Flight of idea Poverty of speech Confabulation Loosening of association Neologisme
Circumtansiality Tangential Verbigration Perseveration Sound association Word salad
Echolalia
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Content of Thought
Idea of Reference Idea of Guilt
Preoccupation
Obsession
Phobia
Fantasy
Delusion of Persecution
Delusion of Reference Delusion of Envious Delusion of Hypochondriac
Delusion of Magic-mystic
Delusion of Grandiose Delusion of Control Delusion of Religion Delusion of Influence Delusion of Passivity Delusion of Perception
Delusion of Suspicion Thought of Echo Thought of Insertion &
withdrawal
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Sensorium and Cognition
Level of education : finished junior highschool
General knowledge : good
Orientation of time : goodOrientations of place : goodOrientations of people : goodOrientations of situation : goodWorking/short/long memory: goodWriting and reading skills : goodVisuospatial : cant be accessed Abstract thinking : cant be accessed Ability to self care : good
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Self control: enough Patient response to
examiners question:good
Impaired insight Intellectual Insight True Insight
Impulse controlwhen examined Insight
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Physical State
Consciousnes : compos mentisVital sign :
Blood pressure : 130/90 mmHg Pulse rate : 100 x/min Temperature : Afebrile RR : 22 x/min
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Review System
Head : normocephali, mouth deviation (-)
Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax :
Cor : S 1,2 regular
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm a cral, capp refill
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Mental Status Impairment- Attitude: Cooperative,
hyperactive, bizzare- Mood: Euphoric
- Affect: Appropriate, stabil
- Perception: Gustatory illusion
- Thought Progression: Talkative,
coherrent- Form of Thought: Non-realistic,
fantasy, delusion of suspicionand religion
-Patients response to question:good
- Impaired insight
Didnt take his
medicine Refused going tohospital forroutine control Giving his waresto other peoplewithout anyreason
He didnt work Poor utilization of
leisure time He couldnt
socialize withneighbor
Symptoms
Patient is a male, 43 years old, nicely groomed, has a history of admittion inpsychiatric ward. Symptoms elevation started since 4 days ago.
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Differential Diagnosis
F20.04 Paranoid Schizophrenia incompleteremission
F20.5 Residual Schizophrenia
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Multiaxial Diagnosis
Axis I : F20.00 Continous ParanoidSchizophrenia
Z91.1 Noncompliance of medicationAxis II : Z03.2 noneAxis III : no diagnosisAxis IV : meeting wife and children who didnt
live togetherAxis V : GAF admission 40-31
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RESPONSE PHASE
Target therapy : 50% decrease of symptoms
Emergency department
Haloperidol inj 5mg imDiazepam inj 10mg iv
Maintenance
Risperidone 2x2mg per day
Re-assess patient
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