Morning Report 15 Sept Jiwa

7/24/2019 Morning Report 15 Sept Jiwa

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SUPERVISORSUPERVISOR

dr. Sabar P. Siregardr. Sabar P. Siregar,,

MORNINGMORNING

REPORTREPORT

Monday night shift 15thSeptember2014


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Patient Identity

Name : Ms. Su

Sex : Female

ge : !" years old

ddress : #emanggung

$%%upation : &nemployed ' used to bebabysister(

Marital Status : Single


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RELATIVES IDENTIT

Name : Mr. ) Sex : Male

ge : *1 years old

+elation : Father


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Rea!"n patient #a! br"$g%t t"

e&ergen'y r""&

,atient -as taling to herself/laughing alone/ getting angry easily


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Pre!ent (i!t"ry

n ugust/patient uit her

ob as maid and

returned fromSemarang

be%ause she -as

feelingunsatis3ed -ith

her ob

1 month

ago'2014(


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4 daysago

'2014( ,atient ased for

permission to -or in big%ity but not allo-ed byher parents. hendenied by her parents/she started to get angryeasily.

Impairment :

Patient could not sleep and unable to

communicate well with others


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2 daysago

'2014( ,atient started to tal and

laugh by herself. tnight/ patient %ould notsleep and startedsinging. ,atient -as tiedbe%ause she tried toleae home.

Impairment :Patient could not sleep and unable to

communicate well with others

Patient could not take care of herself

(refused to bathe and poor appetite)


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Stressor

Patient was denied by herparents to work in big city.


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Day ") Ad&i!!i"n15thSeptember

2014

6rought to thehospital

be%ausepatient taledand laughed

by herself

6roughtto the

hospital by herfather'in tied

%ondition(


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PS*(IATRI* (ISTOR

Sin%e 1771 patient -as admittedin +S8 for 5 times for same

reason


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EARL *(ILD(OOD P(ASE + EARSEARL *(ILD(OOD P(ASE + EARS


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EARL *(ILD(OOD P(ASE +- EARSEARL *(ILD(OOD P(ASE +- EARS

OLD/OLD/

Psychomotoric9 #here -ere n" 0a1id data on patients gro-th and deelopment be%ause

her father 3rst time lifting the head '!9* months( rolling oer '!9* months( Sitting '*97 months( ra-ling '*97 months(

Standing '*97 months( -aling9running '7912 months( holding obe%ts in her hand'!9* months( putting eerything in her mouth'!9* months(

Psychosocial

9 #here -ere n" 0a1id data on patients gro-th and deelopment be%auseher father started smiling -hen seeing another fa%e '!9* months( startled by noises'!9* months( -hen the patient 3rst laugh or suirm -hen ased to play/ nor playing

%laps -ith others '*97 months(


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Communication- #here -ere no alid data on -hen patient started bubbling

be%ause her father %ouldn;t remember. '*97 months(

Emotion-#here -ere no alid data on patients rea%tion -hen playing/frightened by strangers/ -hen starting to sho- ealousy or

%ompetitieness to-ards other and toilet training be%auseher father %ouldn;t remember

Cognitive#here -ere no alid data be%ause her father %ouldn;tremember/ su%h as:

9 -hi%h age the patient %an follo- obe%ts/ re%ogni


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INTERMEDIATE *(ILD(OOD +-22 EARSINTERMEDIATE *(ILD(OOD +-22 EARS

OLD/OLD/Psychomotor

No alid data on -hen patient;s 3rst time playing hide andsee/ but patient -as inoled in %ertain ind of sports.

Psychosocial

She ne0er in0"10ed in a 3g%t -ith other ids.

CommunicationShe %a! )e# )riend! at !'%""1during %hildhood.

Emotional

She -as a 4$iet 5id.

CognitiveShe -as an a0erage and di1igent !t$dent.


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LATE *(ILD(OOD 6 TEENAGELATE *(ILD(OOD 6 TEENAGE

P(ASEP(ASESexual development signs & activity

No data on -hen patient get her menar%he. She is attra%ted toopposite sex.

PsychomotorShe often inoled in household %horus lie %ooing

Psychosocial

She dropped out after elementary s%hool and started -oring as ababysister

Emotional

She -as a uite girl.

Communication

,atients has a fe- friends


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ADULT(OOD


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Eriksons stages of psychosocial

development

Stage Basic onflict Important !"entsInfancy(birth to #$ months)

%rust "s mistrust &eeding

!arly childhood(' years)

*utonomy "s shame and doubt %oilet training

Preschool(+ years) Initiati"e "s guilt !,ploration

School age(6-11 years)

Industry vs inferiority School

Adolescence(12-18 years)

Identity vs role confusion Social relationships

Young Adulthood(19-! years)

Inti"acy vs isolation #elationship

-iddle adulthood(/0+ years)

1enerati"ity "s stagnation 2ork and parenthood

-aturity(0+ death) !go integrity "s despair 3eflection on life


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7AMIL (ISTOR

,atient is the 2nd%hild among !siblings

,sy%hiatry history in the family'9(


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Gen"gra&

M=> F>M=> ,#>N# =?>#$@>#A>+


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PS*(OSE8UAL(ISTOR

Patient reali4es that she is female5 and has interests to

male. 6er attitude is appropriate as a female.


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Progression of Disorder

Symptom

+ole Fun%tion

No-Mar%h2014

1771


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Menta1 State

29t%

Septe&ber :2;


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%hopraxia

atatonia%tie negatiismataplexyStreotypyMannerism

utomatism

ommandautomatismMutism%athysia

#i%Somnabulism,sy%homotor agitationompulsie

taxiaMimi%ryAggre!!i0eI&p$1!i0ebulia


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ATTITUDE

ndiferrent pathy

#ension Bependent ,assie Non

%ooperatie

nfantileBistrustLabile,assie negatiismatalepsyerea CexibilityE='ited


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E&"ti"n


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Di!t$rban'e ") Per'epti"n

7epersonali4ation () 7ereali4ation ()


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T%"$g%t Pr"gre!!i"n


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*"ntent ") T%"$g%t an not be assessed

Idea of 3eference

Idea of 1uilt

Preoccupation

$%session

Phobia

7elusion of Persecution

7elusion of 3eference

7elusion of !n"ious

7elusion of 6ipochondry

7elusion of magicmystic

&elusion of grandiose

7elusion of ontrol

7elusion of Influence

7elusion of Passi"ity

7elusion of Perception

7elusion of Suspicious

%hought of !cho

%hought of Insertion 8

withdrawal

%hought of Broadcasting


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7"r& ") T%"$g%t

Non RealisticBereisti%

utismannot be ealuated


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Sen!"ri$& and *"gniti"n

=eel of edu%ation : >lementary s%hool @eneral no-ledge : %an;t be assessed $rientation of time : bad

$rientations of pla%e : good $rientations of people : good $rientations of situation : bad oringDshortDlong memory: good

riting and reading sills : good ?isuospatial : %an;t be a%%essed bstra%t thining : %an;t be a%%essed bility to self %are : poor


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P%y!i'a1 State

ons%iousnes : %ompos mentis?ital sign :

6lood pressure : 11!DE" mmAg

,ulse rate : 72 xDmnt#emperature : febris

++ : 24 xDmnt


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Review System

Aead : normo%ephali/ mouth deiation '9(

>yes : anemi% %onungtia '9(/ i%teri% s%lera '9(/ pupil

iso%ore

Ne% : normal/ no rigidity/ no palpable lymph nodes

#horax :

or : S 1/2 regular

=ung : esi%ular sound/ -hee


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3!S9-! female/ !" years old/ appropriate

a%%ording to her age

+eason to be brought to hospital : ,atienttaled/ laughed by herself/ and easy to getangry

She has been singing loudly at night/diH%ulty in falling asleep/ loss of appetite/poor self9%are


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Menta1Stat$! I&pair&ent

96ehaior: hypera%tie/aggressie/ impulsie9ttitude: ex%ited9Ie%t: inappropriate/eleated9Mood : irritable9#hought progression:

9 Juantity : logorrhea9 Juality : loosening

of asso%iation/irreleant ans-er

9Form of thought: nonrealisti%9ontent of thought :

delusion of grandiose9,atient;s response to

#aling and

laughing byherself

Singingloudly atnight

@etting

angry easily

She %ouldn;tsleep

She %ouldn;t%ommuni%ate-ell -ithothers

,oor self9%are

=oss ofappetite


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BiIerential Biagnosis

F 25.0 S%hipisode -ith ,sy%hoti%>pisode


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M$1tia=ia1 Diagn"!i!

xis : F 25.0 S%hi


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,roblem related to the patient

9 ,atient left her ob be%ause she -as not satis3ed-ith the ob9 ,atient;s parent not allo-ing her to -orin big %ity


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PLANNINGPLANNING

MANAGEMENTMANAGEMENTInpatient +%"!pita1i>ati"n/

ggressie

,oor self9%are=ogorrhea


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RESPONSE P(ASERESPONSE P(ASE

Target t%erapy ? 50L de%rease of symptoms

E&ergen'y depart&entAaloperidol 5mg i.mBia


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REMISSION P(ASEREMISSION P(ASETarget t%erapy ?2@ re&i!!i"n ") !y&pt"&

Inpatient &anage&entontinue the pharma%otherapy: maintenan%eAaloperidol 2 x 5 mg

1.mproing the patient uality of life :#ea%h patient about his so%ial enironment'intera%t -ith her parents/ so%iali


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RE*OVER P(ASERE*OVER P(ASE- *"ntin$e t%e &edi'ati"n, '"ntr"1 t"

p!y'%iatri'9Re%abi1itati"n ? %e1p patient t" 3nd a %"bbyand pr"d$'ti0e !5i11, %e1p patient t" intera'tn"r&a11y #it% %er )a&i1y and neig%b"r

97a&i1y ed$'ati"n ?9e=p1ain t" t%e )a&i1y ab"$t t%e &enta1di!"rder and t%e treat&ent.9Ed$'ate t%e )a&i1y t" !$pp"rt n"t t" e=i1e

t%e patient.9A!5 t%e )a&i1y t" &"nit"r patient pr"gre!!and &a5e !$re t%e patient ta5e &edi'ine a!pre!'ribe.


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%hank you

Morning Report 15 Sept Jiwa

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