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Morning ReportTuesday, October 21
st
, 2014
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PSYCHIATRIC HISTORY
Morning Report
Tuesday, October 21st, 2014
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Chief Complaint
Laughing and talking to himself
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Stressor
The patients girlfriend had already got
married with someone else.
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History of Present Illness
The patient came with his father. His father explains that
He likes to talk and laugh to himself
He cant communicates well with others
His father told that the patient had a relationship with a
woman, but it turned out that his girlfriend had already
married. The patient didnt take his medicine in this pastmonth. Hes unable to perform daily activities well.
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History of Past Illness
Psychiatric illness
The patient was hospitalized once in 2011
General medical illness
There is no history of high fever, seizure, head
trauma, or any other serious illness which
needs hospitalization
Substance abuse History of smoking
No history of use of drugs
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Depiction of Illness
2009 2014Symptoms
Role
Function
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Family History
There is no history of psychiatric illness in
patients family
There is no history of high fever, seizure,
head trauma, or any other serious illness
which needs hospitalization
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Genogram
Description :
: man : divorced
: : woman
: death
: patient
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History of Personal Life
Prenatal
History of pregnancy
The pregnancy was planned
History of birthHe was born in home with the help of dukun beranak
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EARLY CHILDHOOD PHASE (0-3 YEARS OLD)
Psychomotor (No Valid Data)
- There were no valid data on patients growth and development such as:
first time lifting the head (3-6 months) rolling over (3-6 months)
Sitting (6-9 months)
Crawling (6-9 months)
Standing (6-9 months)
walking-running (9-12 months)
holding objects in his hand(3-6 months)
putting everything in his mouth(3-6 months)
Psychosocial (No Valid Data)- There were no valid data on which age patient
started smiling when seeing another face (3-6 months)
startled by noises(3-6 months)
when the patient first laugh or squirm when asked to play, nor
playing claps with others (6-9 months)
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INTERMEDIATE CHILDHOOD PHASE (3-11 YEARS OLD)
Psychomotor (NO VALID DATA)
No valid data on when patients first time playing hide and
seek or if patient ever involved in any kind of sports.
Psychosocial (NO VALID DATA)
No valid data when patient child and his ability to
communicate with other people.Communication (NO VALID DATA)
No valid data on Patientsability to make friends at school.
Emotional (NO VALID DATA)
No valid data on patientsemotional.
Cognitive (NO VALID DATA)
No valid data on patient academic history.
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LATE CHILHOOD & TEENAGE PHASE
Sexual development signs & activity (NO VALID DATA)
No data when patient wet dream etc.
Psychomotor (NO VALID DATA) No valid data on patientsfavourite hobbies or games, if patient
involved in any kind of sports.
Psychosocial (NO VALID DATA)
No valid data regarding patient psychosocial.
Emotional (NO VALID DATA)
No valid data on patientsemotional.
Communication (NO VALID DATA)
No valid data regarding patient ability to make friends at school
and how many friends patient have during his junior high school
period
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ADULTHOOD
Educational History
Hes graduated from
elementary school.
Occupational history
Previously he worked as a
laborer. He had a goodrelationship with his
fellows. But now he wont
do anything.
Marital Status
Single
Criminal History
No criminal history
Social Activity
He is an introvert person but
he has a few close friends
Current Situation
He lives with his parents and
grandfather
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Stage Basic Conflict Important Events
Infancy
(birth to 18 months)Trust vs mistrust Feeding
Early childhood
(2-3 years)
Autonomy vs shame and
doubtToilet training
Preschool
(3-5 years)
Initiative vs guilt Exploration
School age
(6-11 years)Industry vs inferiority School
Adolescence
(12-18 years)Identity vs role confusion Social relationships
Young Adulthood
(19-40 years) Intimacy vs isolation Relationship
Middle adulthood
(40-65 years)Generativity vs stagnation Work and parenthood
Maturity
(65- death)Ego integrity vs despair Reflection on life
Eriksons stages of psychosocial development
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History of Personal Life
SOCIO-ECONOMIC HISTORY
Economic scale : low
VALIDITY
Alloanamnesis : valid
Autoanamnesis : not valid
Patient realizes that he is a male Has interests to female
His attitude is appropriate as a male
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EXAMINATION
Morning Report
Tuesday, October 21st, 2014
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Physical Examination
General physical examination
General appearance :
Good nutritional status
Vital sign :
BP : 120/80 mmHg
HR : 100x/m
to : afebris
RR : 20x/m
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Review System
Head :
normocephali, mouth deviation (-)
anemic conjungtiva (-), icteric sclera (-), pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax :
Cor : S1 S2 regular, murmur -, gallop -
Lung : vesicular sound +/+, wheezing -/-, ronchi-/-
Abdomen : flat, abdominal wall//chest wall, normal peristaltic, tympany
sound, tenderness -, mass -, liver, spleen and kidney not papable
Extremity : Warm acral, capp refill
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Neurogical Examination
Cranial nerves examination:
CN I : in normal finding
CN II : in normal finding
CN III,IV,VI : in normal finding
CN V : in normal finding CN VII : in normal finding
CN VIII : in normal finding
CN IX : in normal finding
CN X : in normal finding
CN XI : in normal finding
CN XII : in normal finding
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Neurogical Examination
Physiological reflex
Upper extremities: biceps reflex (+), triceps reflex (+),
brachioradial (+)
Lower extremities: patella reflex (+), achilles tendon reflex (+)
Pathological reflex Upper extremities: Hoffman (-), Tromner (-)
Lower extremities: babinski (-), chaddok (-),gordon (-),oppenheim
(-), rossolimo (-)
Motoric examination
Normal movement, good coordination, normal strength
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Mental State Examination
Appearance:
a man, appropriate to his age, completely clothed
State of consciousness: clear
Speech:
speak spontaneously, intonation and speech
volume loud, clear articulation, speech
productivity abundant
Tuesday, October 21st, 2014
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Mental State Examination
Behavior 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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Mental State Examination
Attitude: Non-cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile
Labile
Rigid
Passive negativism
Catalepsy
Cerea flexibility
Excited
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Mental State Examination
Disturbance of Perception
Hallucination
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-) Tactile (-)
Somatic (-)
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-) Tactile (-)
Somatic (-)
Depersonalization (-) Derealization (-)
Mental State Examination
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Mental State Examination Thought Progression
Quantity
Logorrhea
Blocking
Remming
Mutism
Talkative
Quality
Irrelevant answer
Coprolalia
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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Mental State Examination Content of Thought
Idea of Reference
Idea of grandiose
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
Thought of Broadcasting
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Mental State Examination
Form of Thought
Non Realistic
Dereistic
Autism Cannot be evaluated
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Sensorium and Cognition
Level of education : finished elementary school
General knowledge : good
Orientation of time : good
Orientations of place : good
Orientations of people : good
Orientations of situation : good
Working/short/long memory: good
Writing and reading skills : good
Visuospatial : good
Abstract thinking : good
Ability to self care : bad
Impulse control when
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Impulse control when
examined Self control: bad
Patient response to examiners question: good
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Insight
Impaired insight
Intellectual Insight
True Insight
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RESUME
Morning ReportTuesday, October 21st, 2014
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Resume
A male, 25 years old, appropriate according to her age
Symptom: Patient liked to talked and laughed to himself alone
since 1 month ago, Patient cant relate well socially, unable toperform daily activities well
Mental Status: Behavior: Stereotypic and psychomotor agitation
Attitude: Excited
Mood: Tension, Labile
Progression of thought: Remming, incohorence
Impairment:
Patient cant do the job
Impairment of social function
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Differential Diagnosis
F20.1 Hebefrenic Schizophrenia
F20.2 Catatonic Schizophrenia
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Multiaxial Diagnosis
Axis I : F20.1 Hebephrenic Schizophrenia ,
Z91.1 Treatment adherence
Axis II : Z03.2 No axis II diagnosis
Axis III : No axis III diagnosis
Axis IV : Problem with his girlfriend
Axis V : GAF admission 50-41
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MANAGEMENT
Morning ReportTuesday, October 21st, 2014
l i
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Management Planning
Hospitalization
Patient has symptoms such as talk and laugh to himself
Patient wont perform a job
Drug adherence
Emergency Department Haloperidol 5mg im
Diazepam 5 mg iv
Wards
Haloperidol 5 mg po 2dd1
Psychotherapy
Response Remission Recovery
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R i i Ph
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Target therapy :
100% remission of symptom
Inpatient management
Haloperidol 5 mg 2 dd I
Improving the patient quality of life :
Teach patient about his social & environment (interact with
his family, socialize with his neighbor or friends, find a
hobby to do on his spare time)
Outpatient management
Pharmacotherapy
Psychosocial therapy
Remission Phase
R Ph
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Continue the medication, control topsychiatric
Rehabilitation:
- Help patient to find a hobby,
- Help patient to interact normally with his
family and neighbor- Family education
Recovery Phase
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Thank You!Tuesday, October 21st, 2014