Documente Academic
Documente Profesional
Documente Cultură
NG
REPORT
Saturday 4
th
October 2014
SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ
PATIENTS IDENTITY
Name
: Mr. H
Sex
: Male
Age
: 82 years old
Address
: Banjarnegara
Occupation
: Unemployed
Marital State
: Widower
RELATIVEs
IDENTITY
Name
Age
Address
Occupation
Education
Relation with
patient
Duration of
Relationship
Strength
I
Mr. M
40 y.o
Wonosobo
Employer (in
Wonosobo)
Senior High School
Son
40 years
Fair
STRESSOR
DAY OF ADMISSION
4th
October 2014
2 weeks ago
he began to
talk by
himself,
getting angry
especially to
his grand
children,
throwing
household,
wandering
around
Brought to
hospital by his
son, because of:
Talk by himself
Throwing
household
Getting angry
Poor grooming
PSYCHIAT
RIC
HISTORY
No psychiatric history
General Medical
History
Progression of Disorder
Symptom 2011
2014
Sympto
ms
Role of
function
Perinatal
No valid data
Psychosocial
Communication
Emotion
Cognitive
Psychosocial
Communication
Emotional
Cognitive
ADULTHOOD
Educational History
He graduated from elementary school, and didnt
continue because of economic problem
Occupational history
He was a farmer and doing well in his job
Marital Status
Widower, his wife dead 5 years ago
Criminal History
No criminal history
Social Activity
He is a sociable person and have many friends
Current Situation
He lives alone, even his children lives near his house
FAMILY HISTORY
The patient is the 3rd child and has 3
siblings
No Psychiatry history in the family
GENOGRAM
PSYCHOSEXUAL
HISTORY
Patient realizes that he is a
male
Has interests to female
His attitude is appropriate as
a male
SOCIO-ECONOMIC HISTORY
Economic scale : low
Patient doesnt have any job now
VALIDITY
Alloanamnesis
: valid
Autoanamnesis : valid
MENTAL STATE
Mental State
Appearance
A male, appropriate to his age, completely
clothed, fair appearance
State of Consciousness
Clear
Speech
Quantity : normal
Quality : Decreased
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
ATTITUDE
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile
Distrust
Labile
Rigid
Passive
negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited
EMOTION
AFFECT
MOOD
Dysphoric
Elevated
Euphoria
Expansive
Irritable
Agitation
Euthymic
Appropriate
Inappropriate
Restrictive
Blunted
Flat
Labile
Wide
DISTURBANCE OF
PERCEPTION
H A L LU C I N AT I O N
Visual (+) : he is
seeing mbah
guru
Auditory (+) : he
listens to mbah
guru advising
him, and he
heard his friends
that was already
dead speaking
Depersonalization
(-)
to him
I L LU S I O N
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Derealization (-)
THOUGHT PROGRESSION
QUANTITY
Logorrhea
Blocking
Remming
Mutism
Talk active
QUALITY
Irrelevant answer
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of
association
Neologisme
Circumtansiality
Tangential
Verbigration
Perseveration
Sound association
Word salad
Echolalia
CONTENT OF THOUGHT
Delusion of grandiose
Idea of Reference
Idea of Guilt
Preoccupation
Obsession
Delusion of reference
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Phobia
Delusion of Persecution
Delusion of Reference
Thought of Echo
Delusion of Envious
Thought of Insertion
Delusion of magic-mystic
Thought of
Delusion of Suspicious
FORM OF THOUGHT
Realistic
Dereistic
Non Realistic
Autism
Cannot be evaluated
SENSORIUM AND
COGNITION
Level of education
: Elementary school
General knowledge
: Poor
Orientation of time
: Poor
Orientations of place
: Good
Orientations of people
: Good
Orientations of situation : Good
Working/short/long memory : poor in
short memory and calculation
Writing and reading skills : not assessed
Visuospatial
: not assessed
Abstract thinking
: not assessed
Ability to self care
: Good
Impulse Control
when Examined
Self control: Good
Patient response to
examiners
question: Good
Insight
Impaired
Insight
Intellectual
Insight
True Insight
PHYSICAL STATE
Consciousness : compos mentis
Vital sign
Blood pressure
: 90/50 mmHg, adult cuff,
left handed
Pulse rate
: 92 bpm, regular
Temperature
: Afebrile
RR
: 18 x/mnt, thoracoabdominal
REVIEW SYSTEM
Head : normocephali, mouth deviation (-)
Eyes : anemic conjungtiva (-), icteric sclera
(-), pupil isocore
Neck : normal, no rigidity, no palpable
lymph nodes
Thorax
Cor
RESUME
A male, appropriate to her age, completely
clothed, fair appearance
Reason to be brought to hospital are:
Talk by himself
Throwing household
Getting angry
Poor grooming
RESUME
Symptom
s
DAY OF ADMISSION
-
Mental
Affect: apropiate, wide
Mood:Status
euthymic
Impairment
- Behaviour: hypoactive
- Attitude: labil
Talk by
himself
Throwing
househol
d
Getting
angry
Poor
grooming
- Perception:
Hallucination of auditory
(+), visual (+)
- Thought Progression:
Remming
- Form of Thought: non
realistic
- Content of thought:
delusion of magic
mystic, thought
insertion, thought
broadcasting
- Patients response to
question: fair
- Poor
grooming
- Can not
communica
te well with
other
Syndrome
- Delusion of control, Delusion of
magic mystic
- Hallucination of auditory (+),
visual (+)
- Remming
- Poor grooming
- Thought insertion, thought
broadcasting
Psychotic
syndrome
Paranoid
syndrome
DIFFERENTIAL
DIAGNOSIS
F20.0
F06.7
MULTIAXIAL
DIAGNOSIS
Axis I
: F20.0 Schizophrenia
Paranoid (late onset)
Axis II
: no diagnosis
Axis III
: TBC
Axis IV
: Lives alone
Axis V
: GAF admission 70-61
Patients problems
Biological problem
Psychotic symptom : neurotransmitter
imbalance in cerebral cortex
Psychological problems
He feels lonely because left by his family
and lives alone
Social Problem
He cant communicate well with others,
leisure time with family is diminished
MANAGEMENT
PLANNING
MANAGEMENT
Inpatient (hospitalization):
Talk by Himself
Throwing Household
Getting angry
Poor grooming
Response
Remiss
ion
Recove
ry
Response Phase
Target therapy :
50% decrease of symptoms
Emergency department
There is no emergency situation
Maintenance
Haloperidol 1,5 mg po 2dd1
Re-assess patient
Remission Phase
Target therapy :
100% remission of symptom
Inpatient management
Risperidone 2mg 1dd1 (decrease the side effect for
long-term antypsycotic usage)
Piracetam 800 mg 2dd1
Improving the patient quality of life :
Teach patient about her social & environment (interact with
her family and child, socialize with her neighbor or friends,
find a hobby to do on her spare time)
Outpatient management
Pharmacotherapy
Psychosocial therapy
Recovery Phase
Continue the medication, control to
psychiatric
Rehabilitation :
- Help patient to find a hobby,
- Help patient to interact normally with
his family and neighbor
- Family education
Family education
All people have a chance to have psychiatric
problem
Psychiatric problem caused by multifactorial
Most of psychiatric problem cause by imbalance of
neurotrasmitter in brain
Psychiatric symptom can be controlled by drugs
Treat patient as a normal person
Please, only help patient if she/he really need help.
Dont ask patient to understand the family
situation, but the family must understand the
patient situation.
Dont get easily angered to the patient.
Thank You