morning report 29.12.13 deps

8/13/2019 morning report 29.12.13 Deps

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Sunday, 29thDecember 2013


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I. PATIENTS IDENTITY

AutoanamnesisName : Ms. SAge : 32 year oldGender : Female

Address : PurworejoOccupation : nemployedMarital status : Single!ast education: Senior "ig# Sc#ool

AlloanamnesisName : Mr. SAge : $2 year old%elation : "er Fat#er


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REASON WHY PATIENT WASBROUGHT TO THE HOSPITAL


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Unclear


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Role dysfunction

Social withdrawal

Role dysfunction

Social withdrawal

Role dysfunction

Social withdrawal


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Lazy to work

Social withdrawal

Poor grooming

Lazy to work

Social withdrawal

Poor grooming


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Psychomotoric (NO VALID DATA) There were no important data on patients growth and development such as:

first time lifting the head (3-6 months) rolling over (3-6 months) Sitting (6-9 months) Crawling (6-9 months) Standing (6-9 months) walking-running (9-! months) holding o"#ects in his hand(3-6 months)

putting ever$thing in his mouth(3-6 months)Psychosocial(NO VALID DATA) There were no important data on which age patient:

started smiling when seeing others face (3-6 months) startled "$ noises(3-6 months) when the patient first laugh or s%uirm when asked to pla$& nor pla$ing claps with others (6-9

months)

Communication (NO VALID DATA) There were no important data on when patient started babbling. (3 months)


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Emotion (no valid data) There were no important data of patient's reaction when pla$ing&

frightened "$ strangers& showed #ealous$ or competitiveness towardsothers and toilet training

Cognitive (no valid data) There were no important data on which age the patient can follow o"#ects&

recognied his mother& recognie his famil$ mem"ers There were no important data on when the patient first copied sounds that

were heard& or understanding simple orders


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Psychomotor (no valid data)

*o data a"out patient's first time riding a tric$cle or "ic$cle& if patient everinvolved in an$ kind of sports

Psychosocial (no valid data)

*o data a"out patient's interaction with his surrounding& or when patient firstentered primar$ school& and how well he pla$ed with his new friend on first da$

of schoolCommunication (no valid data)

Patients ability to make friends at school and how many friends patienthave during his school period is limited. She spent times with her twin sisteronly.

Emotional(no valid data)

*o data a"out patient's adaptation under stress& an$ incidents of "edwetting wereunknown

Cognitive (no valid data)

*o important data on patient's cognitive


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e!ual develo"ment signs # activity (no valid data) *o data on when patient e+perienced menarche& or the growth of armpit and

pu"ic hairPsychomotor (no valid data)

*o data if patient had an$ favourite ho""ies or games& if patient involved inan$ kind of sports

Psychosocial (no valid data) Patient only had a few friends, and more often played with her twins.

Emotional She used to be calm, quiet, and tend to suppress her feelings and anger.

She rarely showed her emotions to others.Communication (no valid data)

*ot important data on how well the relationship "etween patient with parentsand her famil$


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,atient is the 3rd child of 6 si"lings

er twin sister also had some same s$mptoms $ears ago

Family history


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Patient psychosexual history is appropriate of her gender buther interest to men is unknown.


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Symtom

Rol! "#$%tio$

2007 DES 20132005 2006


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&!$tal Stat!' S#$(ay) *+th(!%!m,!r *-/0


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B!ha1io#r

"ypoacti&e '()"yperacti&e*c#opra+ia

,atatoniaActi&e negati&ism,ataple+yStreotypy

MannerismAutomatism-iarre

,ommand automatismMutism '()Acat#ysia

/icSomna0ulismPsyc#omotor agitation,ompulsi&eAta+iaMimicryAggresi&e1mpulsi&eA0ulia


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ATTITUDE

,ooperati&eNoncooperati&e

'() 1ndierrentApat#y/ension '()

4ependentActi&e Passi&e

1nantile4istrust '()!a0ile

%igidPassi&e negati&ismStereotypy,atalepsy

,erea le+i0ility*+citement


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Emotio$


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Tho#2ht ro2r!ssio$


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3o$t!$t o" tho#2ht

4an5t be assessed dea o! /e!erence

reoccupation

6bsession

hobia

Delusion o! ersecution

Delusion o! /e!erence

Delusion o! &n$ious

Delusion o! 7ipochondry

Delusion o! magic'mystic

Delusion o! grandiose Delusion o! 4ontrol

Delusion o! n!luence

Delusion o! assi$ity Delusion o! erception

Delusion o! Suspicious

#hought o! &cho

#hought o!

nsertion8ithdraal

#hought o! :roadcasting


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Form o" Tho#2ht

.ealistic*on .ealistic

/ereistic

0utistic (1)


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Sensorium and Cognition

2evel of education : senior high school eneral knowledge : can't "e assesed 4rientation of time5place5people5situation :

can't "e assesed orking5short5long memor$ : can't "e assesed riting and reading skills : can't "e assesed 7isuospatial : can't "e assesed 0"stract thinking : can't "e assesed

0"ilit$ to self care : poor


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I$t!r$al Stat#s

Conciousnes : compos mentis7ital sign :

8lood pressure : !5; mmg

,ulse rate : ; +5mnt

Temperature : afe"ris

.. : !; +5mnt


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Head : normocephali

yes : anemic con!ungtiva "#", icteric sclera "#", pupil isocore

$eck : normal, no rigidity, no palpable lymph nodes

%hora&:

'or : S (,) Sound and normal

*ung : vesicular sound, whee+ing "#", ronchi"#"

bdomen : Pain -" , normal peristaltic, tympany sound

&tremity : /arm acral, capp refill 0)1


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otoric; / =8=

athological re!le+;

7o!!man'#romer '8', :abinsi '8', 4haddoc '8'


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Di""!r!$tial Dia2$os!

%&'.& $a(or Depressi)e with Psychotic symptoms

%20.02 4athatonic Schi?ophrenia


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7ospitali?ation

o 7ospital treatment plans should be orientedtoard practical issues o! sel!'care, @uality o!li!e, employment, and social relationships

o #o establish an e!!ecti$e association beteenpatients and community support systems


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sychosocial #herapy

o %amily'6riented #herapies &+plain to patient5s !amily about mental disorder.

#reat the patient according to the !amily5s ability

7elp the patient hen she needs it

&ducate the !amily to encourage the communication and understanding


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ltia4ial Dia2$os!

+is ; %32.3 aAor Depressi$e ith sychotic

symptoms

+is ; Schi?oid ersonality #raits

+is ; 00'99 4irculation disease (pre'hypertension)

+is B ; Cnnon

+is B ; % admission 20'11


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,harmacotherap$O


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d $itam ; dubia ad malam

d !unctionam ; dubia ad bonam

d sanationam ; dubia ad malam


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morning report 29.12.13 deps

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