morning report 15 oktober 2012
TRANSCRIPT
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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
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!!.#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&.
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!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
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-ate #hi&dhood = (eenage Phase Se
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*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.
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Psychose
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+cono%ic sca&e: &o
Socio3
econo%ichistory
8&&oana%nesis : va&idCa&idity
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Progression o$ !&nesssy%pto%
Ro&e $unction
Oktober 22 October 212
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!!! Menta& State
Appearance :
)oung %an, appropriate according to age,
dressed appropriate&y, irritab&e
State o1 0onsciousness
#&ear
Speec*: Duantity : high
Dua&ity : high
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Aehaviour
'ypoactive'yperactive+chopra
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8((!(B7+
#ooperative
on3cooperative
!ndi$errent
8pathy
(ension
7ependent 8ctive
Passive
!n$anti&e7istrust-abi&e
RigidPassive negativis%Stereotypy#ata&epsy
#erea Ee
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+%otion
Mood
7ysphoric +uphoria +&evated +
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7isturbance o$ 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
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(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
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(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
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(hought $or% 4orm o1 ,*oug*tRea&istic
on Rea&istic7ereistic
8utis%
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S+SOR!BM and cognition
-eve& o$ 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
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Se&$ contro& : not
enoug* Patient response toe
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!C. P')S!#8- +H8M!8(!O
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!nterna& Status #onciousness : co%pos %entis Cita& sign:
A&ood pressure : 1>5FII %%'g
Pu&se rate : I0
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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