morning report 15 oktober 2012

7/26/2019 Morning Report 15 Oktober 2012

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MorningReport

Monday , October

15th,2012

Supervisor :

dr Sabar P Siregar Sp.K


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!.Patient"s !dentityName : Mr. AmAge : 28 years oldGender: MaleAddress : PurworejoOccupation : UnemployedMarriage status : Singleeligion : !slam"ast education : S# $ %rst semester &

AlloanamnesisName : Mr. AsAge : '( years oldelation : Patient)s mot*er


3/36

!!.#hie$ co%p&aint

Patient o$ten agitated

in anger ande%otiona&&ysensitive.


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Presenting i&&ness

One week ago Patient often gets agitated in anger and easily gets hurt

emotionally.

Patient often destroys and throws things in anger.

Patients is said to hear voices telling taunting him andasking him to kill someone of random names.

( Patient does not know who the voice is referring to. )

Patient is sensitive and suspects people or even

the guest is in this house talks bad about him.


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Patient talks and laughs to himself.

Patient often locks himself in the room.

Patient has difficulty to fall asleep. Said to sleep 2 hours

a day.

Patient often takes a shower each day ( almost 1 times

a day )

!mpaired social functions ( "e always isolates himself )

#eterioration in performing functioning roles$ ability to

care for himself.


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'!S(OR) O* PR+S+(!--+SS

Psychiatry history

October 2002

as ad%itted inRS/ Puri ir%a&a$or to ees.

enera& %edica&history

'ypertension 34 'ead inury 34 *ebri&e seiure 3

4 'istory o$

asth%a 6 4

7rugs and a&coho&abuse history ands%oing history

8&coho&consu%ption 34

(obaccoconsu%ption 64one %onth ago

drug use 34


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'istory o$ Persona& -i$e P+NA,A" AN- P+!NA,A" !S,O/

'is %other as per$ect&y hea&thy hen she as

pregnant. Patient de&ivered through nor%a& de&ivery at

ter% by a doctor at the hospita&.


8/36

!nter%ediate #hi&dhood 9311 y.o4

Psycho%otor o va&id data on hen patient"s rst ti%e riding a tricyc&e or

bicyc&e, i$ patient ever invo&ved in any ind o$ sports.

Psychosocia& (here ere no data on patient"s gender identication,

#o%%unication Patient had %any $riends and socia&ied e&&.

+%otiona& Mother c&ai%s she spent &ess attention on hi% a$ter the

arriva& o$ the second chi&d. Patient as 5 at that ti%e. #ognitive

Su;cient grades and advance%ent to ne


9/36

-ate #hi&dhood = (eenage Phase Se


10/36

*a%i&y 'istory

0urrently t*e eldest son in t*e1amily and lies wit* 3ot* parentsat *ome.

e *as two younger 3rot*er.

No record o1 eit*er parentage*aing mental distur3ance.


11/36

Psychose


12/36

+cono%ic sca&e: &o

Socio3

econo%ichistory

8&&oana%nesis : va&idCa&idity


13/36

Progression o$ !&nesssy%pto%

Ro&e $unction

Oktober 22 October 212


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!!! Menta& State

Appearance :

)oung %an, appropriate according to age,

dressed appropriate&y, irritab&e

State o1 0onsciousness

#&ear

Speec*: Duantity : high

Dua&ity : high


15/36

Aehaviour

'ypoactive'yperactive+chopra


16/36

8((!(B7+

#ooperative

on3cooperative

!ndi$errent

8pathy

(ension

7ependent 8ctive

Passive

!n$anti&e7istrust-abi&e

RigidPassive negativis%Stereotypy#ata&epsy

#erea Ee


17/36

+%otion

Mood

7ysphoric +uphoria +&evated +


18/36

7isturbance o$ perception

'a&&ucination

8uditory

Cisua& O&$actory ustatory(acti&e

So%atic

!&&usion

8uditory

Cisua& O&$actory ustatory(acti&e

So%atic

7epersona&isation 34 7erea&isation 34

%nable to be

assessed

%nable to be

assessed


19/36

(hiningthought progression

Duantity

-ogorrhea A&ocing

Re%%ing Mutis%e(a& active

Dua&ity

!rre&evan anser !ncoherence 4lig*t o1 idea

#on$abu&ation Poverty o$ speech -oosening o$ association eo&ogis%e #ircu%tansia&ity (angentia& Cerbigrasi

Perseverasi Sound association @ord sa&ad +cho&a&ia


20/36

(hought Processcontent o$ thought

!dea of reference

Preokupasi

Obsesi

&obia

#elution of persecution

#elution of suspicious

#elution of envious

#elution of hipokondri

#elusion of magic'mistic

#elusion of control

#elusion of influence

#elusion of passivity#elusion of perception

hought of echo

hought of insertionwithdrawal

hought of broadcasting

%nable to be assessed


21/36

(hought $or% 4orm o1 ,*oug*tRea&istic

on Rea&istic7ereistic

8utis%


22/36

S+SOR!BM and cognition

-eve& o$ education : enough

enera& no&edge : enough

Orientation o$ ti%e : enough p&ace : enough

peop&e : enough

@oringFshortF&ong %e%ory : hard to eva&uate

@riting and reading si&&s : not eva&uated

Cisuospatia& : not eva&uated 8bstract thining : not eva&uated

8bi&ity to se&$ care : not good


23/36

Se&$ contro& : not

enoug* Patient response toe


24/36

!C. P')S!#8- +H8M!8(!O


25/36

!nterna& Status #onciousness : co%pos %entis Cita& sign:

A&ood pressure : 1>5FII %%'g

Pu&se rate : I0


26/36

ead : normocep*ali

+yes : anemic conjungtia 676 icteri9 sclera

676 pupil isocore

Nec9 : normal no rigidity

,*ora5:

0*or : una3le to assess

"ung : una3le to assess

A3domen : una3le to assess

+5tremity : arm acral capp re%ll ;2

morning report 15 oktober 2012

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