morning report - 23 april14
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MORNING MORNING REP O
RT
REP ORT W ednesday , Apr il 23r d 2014
S u p e r v i s
o r :
D r. S a b a r S i r e
g a r, S p K
J
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Patient IdentityPatient Identity
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Relatives IdentityRelatives Identity
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RReasoneason patient ro!"#t topatient ro!"#t to
e$er"en%y roo$&e$er"en%y roo$&
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'tressor'tressor
'till !n%lear
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(ay o) Ad$ission(ay o) Ad$ission
April 20 2014
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PPsy%#iatri%sy%#iatri% *istory*istory
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*ospitali+ation *istory
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Emotion (NO VALID DATA) T#ere ere no valid data o) patient9s rea%tion #en playin",
)ri"#tened y stran"ers, #en startin" to s#o 7ealo!sy or%o$petitiveness toards ot#er and toilet trainin":
Cognitive (NO VALID DATA) T#ere ere no valid data on #i%# a"e t#e patient %an )ollo
o7e%ts, re%o"ni+in" #is $ot#er, re%o"ni+e #is )a$ily $e$ers: T#ere ere no valid data on #en t#e patient rst %opied
so!nds t#at ere #eard, or !nderstandin" si$ple orders:
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INTERME(IATE .*I(*OO( /311 -EAR'INTERME(IATE .*I(*OO( /311 -EAR'
O(O(
Psychomotor (NO VALID DATA)
No valid data on #en patient9s rst ti$e playin" #ide and see6or i) patient ever involved in any 6ind o) sports:
Psychosocial (NO VALID DATA)
No valid data on t#e patient9s psy%#oso%ial develop$ent
CommunicationThe patient has an easy going personality, according to
his father the patient has got quite a lot of friends.
Emotional (NO VALID DATA)
No valid data on patient9s adaptation !nder stress, any in%idents
o) edettin" ere not 6non:
Cognitive (NO VALID DATA)
No valid data on personality patient9s %o"nitive:
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ATE .*I(*OO( ; TEENAGE P*A'EATE .*I(*OO( ; TEENAGE P*A'E
Seual !evelo"ment signs # activity (NO VALID DATA) No data on #en patient9s et drea$ et%:
Psychomotor (NO VALID DATA) No data i) patient #ad any )avo!rite #oies or "a$es, i) patient
involved in any 6ind o) sports:
Psychosocial (NO VALID DATA)• No valid data on t#e patient9s psy%#oso%ial develop$ent
Emotional (NO VALID DATA)
No valid data on patient9s rea%tion on playin", s%ared, s#oed 7ealo!sly or %o$petitiveness
Communication• The patient had no diculty to communicate with the family
and friends, he was quite open about his problems to hisbrother and his parents:
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A(
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Eri6son9s sta"es o)Eri6son9s sta"es o)
psy%#oso%ial develop$entpsy%#oso%ial develop$entStage Basic Conict Important !ents
In)an%y/irt# to 1= $ont#s
Tr!st vs $istr!st >eedin"
Early %#ild#ood/23 years
A!tono$y vs s#a$e anddo!t
Toilet trainin"
Pres%#ool/3? years
Initiative vs "!ilt E@ploration
'%#ool a"e/11 years
Ind!stry vs in)eriority '%#ool
Adoles%en%e
/121= years
Identity vs role %on)!sion 'o%ial relations#ips
-o!n" Ad!lt#ood/1540 years
Inti$a%y vs isolation Relations#ip
Middle ad!lt#ood/40? years
Generativity vs sta"nation Wor6 and parent#ood
Mat!rity/? deat#
E"o inte"rity vs despair Ree%tion on li)e
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>a$ily *istory>a$ily *istory
0Patient is t#e 1st %#ild o!t o) 2silin"s:
0Psy%#iatry #istory in t#e )a$ily /
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• Suffers from
mental illness
• Female
• Male
GENOGRAMGENOGRAM
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Psy%#ose@!al *istoryPsy%#ose@!al *istory
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Symptom
"olefunction
#rogression of $isorder
2 years
agonow4 years
ago
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Mental 'tateMental 'tate
AprilApril 2020 20142014
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•*ypoa%tive•%yperacti!e•E%#opra@ia
•.atatonia•&cti!e negati!ism•.ataple@y•'treotypy
•Manneris$•A!to$atis$•Bi+arre
•.o$$anda!to$atis$•M!tis$
•A%at#ysia• Ti%•'o$na!lis$•Psy%#o$otor a"itation•.o$p!lsive•Ata@ia•Mi$i%ry•&ggresi!e•I$p!lsive
•A!lia
Be#avio!rBe#avio!r
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• 'on(cooperati!e
• Indi)errent• Apat#y• Tension• (ependent
• Passive
•In)antile•$istrust•aile
•Ri"id•Passive ne"ativis$•'tereotypy•.atalepsy
•.erea e@iility•E@%ited
Attit!deAttit!de
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E$otionE$otion
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(ist!ran%e o) per%eption
(epersonali+ation / (ereali+ation /
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T#o!"#t pro"ression
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.ontent o) t#o!"#t
• Idea o) Re)eren%e
• Idea o) G!ilt
• Preo%%!pation
• Osession
• P#oia
• (el!sion o) Perse%!tion
•
(el!sion o) Re)eren%e• (el!sion o) Envio!s
• (el!sion o) *ipo%#ondry
•
(el!sion o) $a"i%$ysti%
• (el!sion o) "randiose
•
(el!sion o) .ontrol• (el!sion o) In!en%e
• (el!sion o) Passivity
•(el!sion o) Per%eption
• (el!sion o) '!spi%io!s
• T#o!"#t o) E%#o
• T#o!"#t o) Insertion ;it#draal
• T#o!"#t o) Broad%astin"
• Can not be assessed
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>or$ o) t#o!"#t
•Realisti%•Non Realisti%•(erealisti%
•&utism
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Sensorium and Cognition
evel o) ed!%ation & C!nior #i"# s%#ool General 6noled"e & %an9t e assessed Orientation o) ti$e & ad
Orientations o) pla%e & ad Orientations o) peoples & ad Orientations o) sit!ation & ad Wor6in"Ds#ortDlon" $e$ory& %an9t e
assessed
Writin" and readin" s6ills & %an9t eassessed
is!ospatial & %an9t e assessed Astra%t t#in6in" & %an9t e assessed Aility to sel) %are & ad
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#hysical Status
.ons%io!snes & %o$pos $entisital si"n &
◦ Blood press!re & 100D0$$*"
◦ P!lse rate & ==@D$nt◦ Te$perat!re & A)eris
◦ RR & 22@D$nt
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*ead & nor$o%ep#ali, $o!t# deviation /
Eyes & ane$i% %on7!n"tiva /D, i%teri% s%lera /D, p!pil
iso%ore
Ne%6 & nor$al, no ri"idity, no palpale ly$p# nodes
T#ora@&
.or & ' 1,2 re"!lar
!n" & vesi%!lar so!nd, #ee+in" D, ron%#iD
Ado$en & Pain / , nor$al peristalti%, ty$pany so!nd
E@tre$ity & War$ a%ral, %app rell F2, $otori% stren"t#
Ne!rolo"i%al e@a$ & not e@a$ined
5
5
5
5
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)entalStatus
Impairment
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(iHerential (ia"nosis
>20:2 .atatoni% '%#i+op#renia>2?:0 '%#i+oaHe%tive Mani% Type
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Prole$ related to t#eProle$ related to t#e
patientpatient
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PANNING MANAGEMENTPANNING MANAGEMENT
Inpatient +hospitaliation-0 Be#avio!r& #ypera%tive, a""ressive, a%tive ne"ativis$
0 Attit!de&non%ooperative, distr!st
0 Mood & A"itation, aHe%t & appropriate
0 T#o!"#t pro"ress& o"orr#ea, >li"#t o) ideas; loosenin" o)asso%iation
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RE'PON'E P*A'ERE'PON'E P*A'E
Target therapy ?0J de%rease o) sy$pto$s/s!dden ra$pa"e ,tal6in" "ieris#,restless,#ypera%tive,a""ressive,
non%ooperative, i"#t o) ideas; loosenin" o) asso%iation
mergency departmentAntipsy%#oti%s &In7: *aloperidol ?$" IM(ia+epa$ 1 a$p I
#lan of TherapyE.TAntipsy%#oti% & *aloperidol 2@2 $"
"e(assess patient
REMI''ION P*A'EREMI''ION P*A'E
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REMI''ION P*A'EREMI''ION P*A'ETarget therapy
/001 remission of symptom /s!dden ra$pa"e,tal6in" "ieris#, restless,#ypera%tive,a""ressive,non%operative,i"#t o) ideas; loosenin" o)asso%iation
Inpatient management1: .ontin!e t#e p#ar$a%ot#erapy2: I$provin" t#e patient 8!ality o) li)e y doin" so%ialvo%ational s6ills trainin" s!%# learn "ood #y"iene,
prepare $eals and #ave etter %o$$!ni%ation:
2utpatient management1: P#ar$a%ot#erapy2: Psy%#oso%ial t#erapy
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T *ANK - O<T *ANK - O