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MORNING REPORT
Friday, july 19th 2013
Supervisor : dr Sabar P Siregar Sp.KJ
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Patients Identity
Name : Mr. W
Age : 32 years old
Gender : Male
Address : Purworejo
Occupation : UnemployedMarriage status : Single
Religion : Moslem
Last education : STM
AlloanamnesisName : Mrs. P
Age : 60 years old
Relation : mother
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REASON OF VISIT TO HOSPITAL
Patient get angry this morningand he broke his neighbors
window.
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Presenting illness
2001
- Didnt wantto go out
- Talk less
2007
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The day of admission
RageHis father often yelling at him
Loss of appetite
Less eye contact
Talk less and slowly
Poor self grooming
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HISTORY OF PRESENT ILLNESS
Psychiatry history
Yes, 6 years ago
General medicalhistory
Hypertension (-)
Head injury (-)
Convulsion (-)
Asthma (-)
Allergy (-)
Drugs and alcoholabuse history and
smoking history
Alcoholconsumption (-)
Drugs abuse (-)
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History of Personal Life
PRENATAL AND PERINATAL HISTORY
No valid data whether the mother has sufficient nutricient during
pregnancy and routine vitamin capsule during pregnancy
No valid data whether she has stabile emotional condition during
this pregnancy
No valid data whether every month she goes to primary health
care to check her pregnancy
No valid data whether she has no significant medical problemsuch as profuse vomitus , fever, high blood pressure, seizure,
leukorea and bleeding
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Early Childhood Phase (0-3 years old)
Psychomotoric There were no valid data on patients growth and development such
as: first time lifting the head, rolling over, sitting, crawling, standing,
walking-running, holding objects in her hand, putting everything in
her mouth, holding objects in her hand
Psychosocial
There were no valid data on which age patient started smiling when
seeing another face, startled by noises, when the patient first laugh
or squirm when asked to play, nor playing claps with others
Communication There were no valid data on when patient started saying words like
mom or dad, or talks.
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Emotion
There were no valid data of patients reaction when playing,
frightened by strangers, when starting to show jealousy or
competitiveness towards other and toilet training.
Cognitive There were no valid data on which age the patient can follow
objects, recognizing her mother,recognize her family members.
There were no valid data on when the patient first copied sounds
that were heard, or understanding simple orders
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Intermediate Childhood (3-11 years old)
Psychomotor
No valid data on when patients first time riding a tricycle or bicycle, if patient
ever involved in any kind of sports.
Psychosocial
There were no data on patients gender identification, interaction with her
surroundings
There were no data on when patient first entered primary school, how wellpatient handles seperation from parents, how well she plays with new friends on
first day of school
Communication
There were no valid data regarding patients ability to make friends in school, and
how many friends patient have during her schooling period.
Emotional
No valid data on patients adaptation under stress, any incidents of bedwetting
were not known.
Cognitive
No valid data on patients achievement in school, how well patient;s reading
ability and grades.
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Late Childhood & Teenage Phase
Sexual development signs & activity
No valid data on when patient experience wet dream, hair on armpits and pubis,etc
Psychomotor
No valid data if patient had any favourite hobbies or games, if patient involved in
any kind of sports.
Psychosocial
No valid data if while growing up did he make many friends, how well patient
make any friends and how much friends.
No valid data on when and how patients relationship with different gender, if
patient ever had any relationship with the opposite gender.
Emotional
No valid data if patient ever told friends or family regarding any problems.
No valid data if patient attempted to break the rules (truant schools subject, fight
with friends, bullying, etc) and consuming alcohol, smoke and drugs
Communication
No valid data on how well the relationship between patient with parents and other
family.
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Adulthood
Educational historyPatient has graduated from
high school
Occupational
historyUnemployed (never)
Marriage status
Single
Legal historyNo data
Social activitypatients withdrew from his social
activity
Current situationHe lived with his parents and siblings
Religion historyHe prays everyday until now
He didnt follow any religion
organization
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Family History
Patient is the 1st child from 5 siblings
He lived with his parents, one brother, and
one sister.
In his family his first younger brother has
mental disoder history.
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Psychosexual history
Patient psychosexual history is appropriate
of his gender and attracted to woman
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Genogram
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Socio-economic history
Economic scale: low
Validity
Alloanamnesis : valid
Autoanamnesis : valid
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Progression of Ilness
symptom
Rolefunction
2001 2007 2013
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Mental State ( Friday 19 July 2013)
Appearance :
Man, appropriate according to age, poor grooming
State of Consciousnessclear
Speech:
Quantity: decrease
Quality : decrease
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Behaviour
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativismCataplexy
Streotypy
Mannerism
AutomatismBizzare
Command automatismMutism
Acathysia
Tic
SomnabulismPsychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia
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ATTITUDE
Cooperative
Non-cooperative
Indiferrent Apathy
Tension
Dependent
Active
Passive
Infantile
Distrust
Labile
RigidPassive negativism
Stereotypy
Catalepsy
Cerea flexibilityExcitement
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Emotion
Mood
Euthymic
Hipothym Dysphoric
Euphoria
Elevated
Expansive Irritable
Cant be assesed
Affect
Appropriate Inappropriate
Restrictive
Blunted
Flat Labile
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Disturbance of perception
Hallucination
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Illusion
Auditory (-)
Visual (-) Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Derealisation (-)Depersonalisation (-)
Thi ki
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Thinking
thought progression
Quantity
Logorrhea
Blocking
RemmingMutisme
Talk active
Quality
Irrelevant answer
Coherence
Flight of idea
Confabulation
Poverty of speech
Loosening of association
Neologisme
CircumstansialityTangentiallity
Verbigration
Sound association
Perseveration
Word salad
Echolalia
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Thought Process content of thought
Idea of reference
Preokupasi
Obsesi
Fobia
Delution of pursued
Delution of suspicious
Delution of envious
Delution of hipokondri
Delusion of magic-mistic
Delusion of control
Delusion of influence
Delusion of passivity
Delusion of perception
Delusion of grandeur
Thought of echo
Thought of insertion/withdrawal
Thought of broadcasting
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Thought process
Form of Thought
Realistic
Non RealisticDereistic
Autistic
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Sensorium and Cognition
Level of education : enough
General knowledge : enough
Orientation of time/place/people/situation:
enough Working/short/long memory: enough
Writing and reading skills : enough
Visuospatial : enough
Abstract thinking : enough
Ability to self care : enough
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goodImpulse
control whenexamed
Impaired insight Intelectual Insight
True Insight (4)
Insight
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Internal Status
Conciousnes: compos mentis
Vital sign:
Blood pressure : 160/90 mmHg
Pulse rate : 104 x/mnt
Temperature : afebris
RR : 20 x/mnt
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Head: mesocephali
Eyes: anemic conjungtiva -/-, ikteric sclera -/-, pupil isocor
Neck: normal, no rigidity, no palpable lymphnode
Thorax:
Cor: S1 and S2 sound and normal
Lungs: vesicular sound, wheezing -/-, ronchi-/-
Abdomen: pain -, peristaltic normal, thympany sound
Extremity: acral temperature, cappillary refill < 2 second
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SIGNIFICANT FINDING RESUME
Onset: yesterday morning
Symptoms
- Loss of appetite
- Deteriorate self
grooming- Rage
Disability
Poor selfgrooming
Mental StatusCooperative
Mood :elevated
Afect: flat,inappropriate
Stereotypy
Remming
hallucination and delusion ()
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Differential Diagnose
F20.3 Schizophrenia Residual
F 20.4 Depression post Schizophrenia
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Multiaxial Diagnose
Axis I : F20.3 Schizophrenia Residual
Axis II : R 46.8 delayed axis II
Axis III : No diagnosis
Axis IV : His father often yelling at him
Axis V : GAF admission 40
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Therapy
Hospitalization To establish an effective association between patients and
community support systems
Hospital treatment plans should be oriented toward practicalissues of self-care, quality of life, employment, and social
relationships.
FAMILY EDUCATION :
- explain to the patient about test results.
- explained to the patient's family know about this :
1. Help if the patient need help but not passive2. Not too much advise
3. Families must understand the patient
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Medicamentosa :
Lodomer inj 1 amp 10 mg
Diazepam inj 1 amp 5 mg
Haloperidol 2x5 mg ROOM
IGD
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THANK YOU