Академический Документы
Профессиональный Документы
Культура Документы
REPORT
SUPERVISOR
dr. Sabar P. Siregar, S
Patient Identity
Autoanamnesis
Name
: Mr. B
Sex
: Male
Age
: 24 years old
Address
: Purworedjo
Occupation
: Unemployed
Marital State
: Single
Alloanamnesis
Name
: Mrs. S
Sex
:Female
Age
: 54 years old
Relation
: Mother
Stressor
Unclear
Day of Admission
17th May 2014
Brought to
hospital by his
mother
He didnt work
Poor utilization of leisure time
He couldnt socialize with friends
Past History
June 2013
Patient was given risperidone and clozapine and got bettter after care.
Patient discontinued medication after being discharged from hospital because he lives far from hospital (not acessible)
PSYCHIATRIC HISTORY
Drugs and
alcohol abuse
history and
smoking
history
General
medical
history
Basic Conflict
Important Events
Infancy
(birth to 18 months)
Trust vs mistrust
Feeding
Early childhood
(2-3 years)
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
Maturity
(65- death)
Reflection on life
FAMILY HISTORY
Patient
Psychiatry
GENOGRAM
MALE
FEMALE
Patient
PSYCHOSEXUAL
HISTORY
Patient realizes that he is a male, and
interests to a female. His attitude is
appropriate as a male.
Progression of Disorder
Symptom
June
2013
Role Function
May
2014
Mental State
7th May 2014
BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizarre
Command
automatism
Mutism
Acathysia
Tic
Somnabulism
Psychomotor
agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia
ATTITUDE
Noncooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile
Distrust
Labile
Rigid
Passive
negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited
Emotion
Disturbance of Perception
Depersonalization (-)
Derealization (-)
Thought Progression
Content of Thought
Idea of Reference
Delusion of grandiose
Idea of Guilt
Delusion of Control
Preoccupation
Delusion of Influence
Obsession
Delusion of Passivity
Phobia
Delusion of Perception
Delusion of Persecution
Delusion of Suspicion
Delusion of Reference
Thought of Echo
Delusion of Envious
Delusion of Hypochondriac
Delusion of magic-mystic
withdrawal
Thought of Broadcasting
Form of Thought
Realistic
Non Realistic
Dereistic
Autism
Cannot be evaluated
Impulse control
when examined
Insight
Physical State
Consciousnes
Vital
: compos mentis
sign :
Blood pressure
: 130/80 mmHg
Pulse rate
: 73 x/mnt
Temperature
: afebrile
Respiration rate
: 22 x/mnt
Review System
Eyes
Neck
Thorax:
Cor
: S 1,2 regular
Lung
RESUME
Day of admission
Patient is a male, 53 years old, poor grooming, has a history of adminition in
psychiatric ward. Symptoms elevation started since half month ago.
Mental
Status
Symptoms
Got angry
easily
Cutting
neighbors
trees
Wandering
around
home
holding an
axe
Hypoactive
Mood: Euthymic
Affect: Restrictive
Perception: none
Thought Progression:
Blocking, poverty of
speech
Impairment
He didnt work
Poor utilization
of leisure time
He couldnt
socialize with
neighbor
Differential Diagnosis
F20.3 Undifferentiated Schizophrenia
F20.5 Residual Schizophrenia
Multiaxial Diagnosis
Axis I
: F20.3 Undifferentiated
Schizophrenia
Z91.1 Noncompliance of
medication
Axis II : Z03.2 none
Axis III: none
Axis IV : Social problem (disturbing
neighbor)
Axis V
: GAF admission 20-11
PLANNING MANAGEMENT
Inpatient (hospitalization)
To reduce 50% the symptoms :
Got angry easily
Wandering around home holding
an axe
Cutting down neighbors trees
without any reason
RESPONSE PHASE
Target therapy : 50% decrease of symptoms
Emergency department
Haloperidol inj 5 mg
Diazepam tab 5 mg
Maintenance
Haloperidol 2x5mg
Re-assess patient
REMISSION PHASE
Target therapy :
100% remission of symptom
Inpatient management
Continue the pharmacotherapy: maintenance
Haloperidol 2x5mg
Improving the patient quality of life :
Teach patient about his social & environment
(interact with his parents, socialize with his neighbor,
get a new job, find a hobby to spend his spare time)
Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy
RECOVERY PHASE
- Continue medication, control to
psychiatric
- Rehabilitation : help patient to find a
hobby, help patient to interact
normally with his family and neighbor
- Family education
Thank You