Professional Documents
Culture Documents
Patients Identity
1.
2.
3.
4.
5.
6.
7.
8.
Name
Age
Sex
Address
Job
Marital status
Ethnicity
Educational status
: AS
: 24 years old
: Male
: Magelang
: Unemployed
: Single
: Javanese
: Junior High School
Identity
Alloanamnesis was conducted to :
I
II
Mr. I
Mr. H
Age
57 years old
33 years old
Sex
Male
Male
Magelang
Magelang
Teacher
Entrepreneur
Educational
status
SPG
Undergraduate
Relationship
Uncle in Law
Brother in Law
Duration of
relationship
7 years
7 years
Strength of
relationship
Fair
Fair
Name
Address
Job
Psychiatric History
Morning Report
Thursday October 3rd , 2014
Chief Complaint
Agitation
Rampage
Destroyed household
Depiction of Illness
Symptoms
2010
Role
Function
2014
2011
Family History
There is history of psychiatric illness in his
mothers aunt.
There is no history of high fever, seizure,
head trauma, or any other serious illness
which needs hospitalization
Genogram
There was no valid data in patients psychomotor aspect (such as tilting the b
ody, supine to prone, sitting, standing, walking, smiling, holding her own ha
nd, scoop up object, holding pencil and pilling up two objects)
Psychosocial
There was no valid data in patients psychosocial aspect (such as replying to s
mile, smiling when seeing interesting object, playing cilukba, knowing her fa
mily members and pointing what she wanted without crying)
Communication
There was no valid data in patients communication aspect (such as bubblin
g, cooing, making sounds without meaning, telling 2-3 syllables without me
aning and calling mama/papa)
Emotion
There no valid data in patients emotion aspect (such as when patient playin
g, frightened by strangers, starting to show jealousy or competitiveness tow
ards other, and toilet training)
Patient didnt pee or defecate in her pants when she was two years old
Cognitive
There was no valid data in patients cognitive aspect (such as copying sounds
that she heard for the first time and understanding simple orders)
o
o
No valid data on when patients first time playing hide and seek or if pati
ent ever involved in any kind of sports.
Psychosocial
Patient was an introvert boy. He seldom played with his peer.
Patients parents always spoiled him. They never got angry to him. It mad
e him dared to resist his parents.
Communication
Patient didnt have any trouble to communicate with others (such as intr
oducing herself and talking with others).
Emotion
Patient was a shy boy and didnt use to showing his emotion.
Cognitive
Patient started his school in elementary school when he was 7 years old.
He was not really a smart boy and had failed a grade..
No valid data if patient had any favorite hobbies or games, if patient involve
d in any kind of sports.
Psychosocial
Patient was an introvert boy. He seldom played with his peer.
Patients parents always spoiled him. They never got angry to him. It made
him dared to resist his parents.
Communication
Patient didnt have any trouble to communicate with others (such as introd
ucing herself and talking with others)
Emotion
Patient was a shy boy. He was quite and often day dreaming. Patient could
nt resist stressors and tended to get stressed out.
Cognitive
After graduating from elementary school, patient continued to study to jun
ior high school. Patient had a poor achievement in academic.
After graduating from junior high school, patient continued to senior high
school until 2nd grade. He dropped out because he lack of interest in study.
He once skipped school because he was unable to solve his homework.
o Occupational
Patient had work in Yogyakarta for 2 days as a labor. Patient stopped working
for unclear reason.
Then he went to Kalimantan, worked in a plantation for one month. After th
at, patient stopped working. He went home because he said that he want to
get married.
o Marital status
Patient has not got married yet.
o Criminal
He has no criminal history
o Social activity
Patient was an introvert, he seldom played with his peer. He is quite and ofte
n day dreaming.
o Current situation
Patient lives with her mother, father, and brothers. His brother currently enter
s the collage.
Basic Conflict
Important Events
Trust vs mistrust
Feeding
Toilet training
Preschool
(3-5 years)
Initiative vs guilt
Exploration
School age
(6-11 years)
Industry vs inferiority
School
Adolescence
(12-18 years)
Social relationships
Young Adulthood
(19-40 years)
Intimacy vs isolation
Relationship
Middle adulthood
(40-65 years)
Generativity vs stagnation
Reflection on life
Infancy
(birth to 18 months)
Early childhood
(2-3 years)
Maturity
(65- death)
Examination
Morning Report
Thursday October 3rd , 2014
Physical Examination
Morning Report
Thursday October 3rd , 2014
o Vital sign
BP : 110/70 mmHg
HR : 94x/m
to : afebris
RR: 20x/m
Lung
Abdomen
Extremity
Neurological examination
Level of Consciousness :
o compos mentis, E4V5M6 (15)
General Appearance :
o Body posture : normal
o Abnormal movement : o Walking style : normal
Neurological examination
Cranial nerves examination:
o
o
o
o
o
o
o
o
o
o
CN I
CN II
CN III,IV,VI
CN V
CN VII
CN VIII
CN IX
CN X
CN XI
CN XII
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
Neurological examination
Motoric
o Upper extremities: tonus (+), trophy : eutrophic, power of movement
: shoulder joint : 5, elbow joint : 5, wrist joint : 5, radial nerve functio
n : 5, ulnar nerve function : 5, median nerve function : 5
o Lower extremities: tonus (+), trophy : eutrophic, power of movement
: hip joint : 5, knee joint : 5, ankle joint : 5
Sensorium
o DCML system : proprioception, fine touch : no abnormalities
o AL system : vibration, temperature, crude touch, pain : no abnormalit
ies
Neurological examination
Physiological reflex
o Upper extremities: biceps reflex (+), triceps reflex (+), brachioradial (+)
o Lower extremities: patella reflex (+), achilles tendon reflex (+)
Pathological reflex
o Upper extremities: Hoffman (-), Tromner (-)
o Lower extremities: babinski (-), chaddok (-),gordon (-),oppenheim (-), rossoli
mo (-), clonus -/-
Meningeal sign
o Neck stiffness (-), brudzinski neck sign (-), brudzinski contralateral leg sign (-),
kernig sign (-)
Cerebellum function
o Adhyadokokinesia (-), romberg test (-), finger to nose test (no abnormalities),
tip to toe walk (no abnormalities)
General Appearance
A man, age 24 years old, appropri
ate to his age, fair grooming
Consciousness
Clear
Orientation
Time
: good
People : good
Place
: good
Situation : good
Behavior
o
o
o
o
o
o
o
o
o
o
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizzare
o Command automatism
o
o
o
o
o
o
o
o
o
o
o
Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia
Attitude
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Non-cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited
Emotion
Affect
Mood
Dysphoric
Depressed
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Inappropriate
Broad
Restrictive
Blunted
Flat
Labile
Disturbance in Perception
Hallucination
Auditory (+)
Visual (+)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-)
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Derealization (-)
Progression of Thought
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
Content of Thought
Idea of Reference
Preoccupation
Obsession
Phobia
Fantasy
Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hypochondriac
Delusion of Magic-mystic
Idea of suicidal
Delusion of Grandiose
Delusion of Control
Delusion of Religion
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Idea of Suspicion
Thought of Echo
Thought of Insertion &
withdrawal
Thought of Broadcasting
Form of Thought
Non Realistic
Dereistic
Autism
Cannot be evaluated
Cognitive Function
Level of education
: finished junior high school
General knowledge
: good
Working/short/long memory : good
Writing and reading skills : good
Visuospatial
: good
Abstract thinking
: good
Ability to self care
: fair
Insight
Impaired insight
Intellectual Insight
True Insight
Resume
Morning Report
Thursday October 3rd, 2014
Resume
Symptom:
o
o
o
o
o
o
o
o
o
o
o
Mental Status:
o
o
o
o
o
o
Behavior : hypoactive
Mood : depressed
Affect : blunted
Perception : auditory and visual hallucination
Content of thought : idea of suicidal, idea of suspicion, delusion of control, thought insertion and withdrawal, thought of broadcasting
Form of thought : non realistic
Impairment:
o Patient cant socialize with others
o Patient has fair grooming
o Patient cant work
Syndrome
Irritable
Easily got angry
Destroyed household
Wandered around
Got rampage
Visual and auditory hallucination
Psychotic Syndrome
Blunted
Idea of suicidal, idea of suspicion,
delusion of control, thought insertion
and withdrawal, thought of
broadcasting
Non realistic form of thought
Couldnt get enough sleep
Depressed mood
Sitting desperately
Depression Syndrome
Diagnosis
Morning Report
Friday September 26th, 2014
Differential Diagnosis
F20.0 Schizophrenia paranoid
F20.2 Schizophrenia catatonic
F25.1 Depressive type schizoaffective disorder
Multiaxial Diagnosis
Management
Morning Report
Friday September 26th, 2014
Patients problems
Biological problem
o Positive symptoms because of increase amount of dopamine in the post sinap
s neuron
Psychological problems
o Patient couldnt resist stressors and tended to get stressed out
Social problem
o He has no work
o He cant socialize well with others
Management Planning
Hospitalization
o Patient was hospitalized because :
the idea of suicidal
troubling others by agitated, easily get angry and destroying household
fair grooming
the appearance of the positive symptom (delusion, hallucination, etc)
Response Phase
o Target therapy :
50% decrease of symptoms
o Emergency department
Diazepam Inj 5 mg IV (for its sedative and muscle relaxation effe
ct)
Haloperidol Inj 5 mg IM (to reduce positive symptoms)
o Maintenance
ECT (to reduce the positive symptoms, especially when patient tri
ed to suicide)
Haloperidol Tab 5 mg PO 2x1 (to reduce positive symptoms)
o Re-assess patient
Remission Phase
Target therapy :
o 100% remission of symptom
Inpatient management
o Risperidone Tab 2mg PO 1x1 (to reduce the positive sympto
m and decrease the possibilities of side effect)
o Improving the patient quality of life :
Teach patient about her social & environment (interact with her f
amily, socialize with her neighbor or friends, find a hobby to do
on her spare time)
Outpatient management
o Continuation of pharmacotherapy
o Psychosocial therapy
Recovery Phase
Continue the medication, control to psychi
atrist
Rehabilitation :
- Consult to psycholog to help patient to fi
nd a hobby
- Help patient to interact normally with her
family and neighbor
Family Education
Explain to the family that anyone could have mental disorders
Mental disorders are caused by multifactorial factor, not by ge
netic
Mental disorders mostly are affected by chemical imbalance in
brain
Mental disorders can be controlled by medicines, so it is impor
tant to take the medicines routinely
Treat patient like you treat any other people
Help patient if he should be helped
Dont push patient to understand the family, but his family tha
t has to understand him
Dont be too emotional to patient
Thank You!
Sayounara!
Thursday October 3rd , 2014