Professional Documents
Culture Documents
Supervisor:
dr Sabar P Siregar Sp.KJ
• Name :
• Age :
• Gender :
• Address :
• Occupation :
• Marriage Status :
• Religion :
• Last Education :
Guardian
• Name :
• Age :
• Relation :
Patient is brought to the hospital by ... due to
...
Time (onset) Time (onset)
Medication
Trauma
Slow, steady growth: 3 -4 inches per Use language as acommunication tool Friendships are situation
year Perspective taking: specific
Use physical activities 5-8 yr: can recognize others’ Understands concepts
to develop gross and fine motor skills perspectives, can’t assume the role of of right and wrong
Motor & perceptual the other Rules relied upon to
motor skills better integrated 8–10 yr: recognize difference between guide behavior and play, and provide
10-12 yr: puberty behavior and intent; age child with structure and security
begins for some children 10-11 yr: can accurately 5-6 yr: believe rules can
recognize and consider be changed
others’ viewpoints 7-8 yrs: strict adherence
Concrete operations: to rules
Accurate perception of 9-10 yrs: rules can be
events; rational, logical negotiated
thought; concrete thinking; reflect upon Begin understanding social roles;
self and attributes; understands regards them as inflexible; can adapt
concepts of space, time, dimension behavior to fit different situations;
Can remember events practices social roles
from months, or years Takes on more responsibilities at home
earlier Less fantasy play, more
More effective coping skills team sports, board games
Understands how his Morality: avoid punishment; self
behavior affects others interested exchanges
Emotional Possible effects of maltreatment
Self esteem based on ability to perform and produce Poor social/academic adjustment in school: preoccupied, easily
Alternative strategies for dealing with frustrationand frustrated, emotional outbursts, difficulty concentrating, can be
expressing emotions overly reliant on teachers; academic challenges are threatening,
Sensitive to other’s opinions about themselves cause anxiety
6-9 yr: have questions about pregnancy, intercourse, Little impulse control, immediate gratification, inadequate coping
sexual wearing, look for nude pictures in books, skills, anxiety, easily frustrated, may feel out of control
magazines Extremes of emotions, emotional numbing; older children may
10-12 yr: games with peeing, sexual activity (e.g., “self-medicate” to avoid negative emotions
strip poker, truth/dare, boy-girl relationships, flirting, Act out frustration, anger, anxiety with hitting, fighting, lying,
some stealing, breaking objects, verbal outbursts, swearing
kissing, stroking/rubbing, reenacting intercourse with Extreme reaction to perceived danger (i.e.,“fight, flight, freeze”
clothes on) response)
May be mistrustful of adults, or overly solicitous,manipulative
May speak in unrealistically glowing terms about his parents
Difficulties in peer relationships; feel inadequate around peers;
over-controlling
Unable to initiate, participate in, or complete activities, give up
quickly
Attachment problems: may not be able to trust, tests commitment
of foster and adoptive parent with negative behaviors
Role reversal to please parents, and take care of parent and
younger siblings
Emotional disturbances: depression, anxiety, post traumatic stress
disorder, attachment problems, conduct disorders
Physical Cognitive Social
Psycho-social task is identity formation All of the problems listed in school age
Young adolescents (12-14): selfconscious about section
physical appearance and early or late development; Identity confusion: inability to trust in self to be a
body image rarely objective, negatively affected by healthy adult; expect to fail; may appear immobilized
physical and sexual abuse; emotionally labile; may and without
over-react to parental questions or criticisms; engage in Direction
activities for intense Poor self esteem: pervasive feelings of guilt, self-
emotional experience; risky criticism, overly rigid expectations for self, inadequacy
behavior; blatant rejections of May overcompensate for negative selfesteem by being
parental standards; rely on peer narcissistic,
group for support unrealistically self-complimentary;
Middle adolescents (15-17): grandiose expectations for self
examination of others’ values, May engage in self-defeating, testing, and aggressive,
beliefs; forms identity by organizing perceptions of antisocial, or impulsive
ones attitudes, behaviors, values into coherent “whole”; behavior; may withdraw
identity includes positive self image comprised of Lack capacity to manage intense
cognitive and affective components emotions; may be excessively labile, with frequent and
Additional struggles with identity violent mood swings
formation include minority or biracial status, being an May be unable to form or maintain
adopted satisfactory relationships with peers
child, gay/lesbian identity Emotional disturbances: depression,
anxiety, post traumatic stress disorder,
attachment problems, conduct disorders
Educational History Current Situation
Occupational History
Stage Basic Conflict Important Events
Infancy Trust vs mistrust Feeding
(birth to 18 months)
Early childhood Autonomy vs shame and doubt Toilet training
(2-3 years)
Preschool Initiative vs guilt Exploration
(3-5 years)
School age Industry vs inferiority School
(6-11 years)
Adolescence Identity vs role confusion Social relationships
(12-18 years)
Young Adulthood Intimacy vs isolation Relationship
(19-40 years)
Middle adulthood Generativity vs stagnation Work and parenthood
(40-65 years)
Maturity Ego integrity vs despair Reflection on life
(65- death)
Conclusion: no clear data
Family history
Psychosexual History
Socio-Economic History
• Economic Scale :
Validity
• Alloanamnesis :
• Autoanamnesis :
Symptom
Role of Function
Appearance
State of Consciousness
Speech
- Quantity :
- Quality :
BEHAVIOUR
Mannerism
Hypoactive Psychomotor
Automatism agitation
Hyperactive
Bizarre Compulsive
Echopraxia
Command Ataxia
Catatonia
automatism
Active negativism Mimicry
Mutism
Cataplexy Aggresive
Acathysia
Stereotypy Impulsive
Tic
Abulia
Somnabulism
ATTITUDE
Non-cooperative Passive
Infantile
Indiferrent negativism
Distrust
Apathy Catalepsy
Labile
Tension Cerea flexibility
Rigid
Dependent Excitement
Emotion
Mood Affect
• Appropriate
• Dysphoric • Inappropriate
• Elevated • Restrictive
• Euphoria • Blunted
• Expansive • Flat
• Irritable • Labile
• Can’t be assessed
Disturbance of Perception
Hallucination Illusion
• Auditory (-)
• Auditory (-)
• Visual (-)
• Olfactory (-) • Visual (-)
• Gustatory (-) • Olfactory (-)
• Tactile (-) • Gustatory (-)
• Somatic (-)
• Undeferrentiated (-)
• Tactile (-)
• Somatic (-)
• Undeferrentiated (-)
Derealisation (-)
Depersonalisation (-)
Thought Progression
Quantity Quality
• Irrelevan answer
• Incoherence
• Logorrhea • Flight of idea
• Blocking • Confabulation
• Remming • Poverty of speech
• Slow speech
• Mutisme • Loosening of association
• Talkative • Neologisme
• Circumtansiality
• Tangential
• Verbigrasi
• Perseverasi
• Sound association
• Word salad
• Echolalia
Content of thought
Idea of Reference Delusion of Grandiose
• Realistic
• Non Realistic
• Dereistic
• Autistic
Sensorium and Cognition
Level of education :
General knowledge :
Orientation of time/
place/people/situation :
Working/short/long memory:
Writing and reading skills :
Ability to self care :
Impulse Control When Examined
• Self control :
Insight
• Impaired insight (patient do not know he
is mentally ill)
• Intelectual Insight
• True Insight
Physical examination
Conciousness :
Vital sign:
- Blood pressure :
- Pulse rate :
- Temperature :
- RR :
•Skin : rash(-), petechiae (-)
•Head
• Eye : conjunctival pallor (-), yellowish sclera (-)
• Nose : discharge(-), nasal flare (-)
• Ear : discharge(-)
• Mouth : within normal limit
• Neck : lymphnodes within normal limit
• Lungs : symmetrical, retraction(-), vesicular (+/+),
abnormal lung sounds (-/-)
• Heart : S1, S2 regular, murmur(-), cardiomegaly (-
• Abdomen : Supple, tympany (+), Distention (-), Hepatomegaly (-),
Splenomeogaly (-)
Motorik : Normotonus, good coordination of movement
Meningeal sign : negative
Physiologic reflex : +/+
Patologic reflex : -/-
Onset :
Axis V : GAF
1. Problem about patient’s life (social)
Remissio
Response Recovery
n
Serious risk of suicide
Serious risk of harm to others
Significant self-neglect
Severe depressive symptoms
Severe psychotic symptoms
Lack or breakdown of social supports
Initiation of ECT
Treatment-resistant depression (where inpatient monitoring
may be helpful)
A need to address comorbid conditions (e.g. physical
problems, other psychiatric conditions, inpatient
detoxification)
Maintenance
Target therapy :
- 100% remission of symptom
Inpatient management
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Outpatient management
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