Morning report

Tuesday, 08-05-2012

5/20/12

Supervisor : Master subtitle style Click to edit dr. Sabar P. Siregar, Sp.Kj

Patient identity

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Alloanamnesis

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Chief complaint

Patient talked alone + 3 months before admission

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History of Present Illness

3 months before admission

1 week before admission

Patient talked to him self Loss of appetite Sleep disturbance (initial insomnia) Liked being alone Patient thought that his friend would like to do harm Easily irritated Patient talked to him self he saw a shadow, Patient thought that Easily irritated and hear that someone called him Loss of appetite
Sleeping disturbance Like being alone Patient thought that he saw a shadow, and hear that someone called him. Patient felt that someone chasing him 5/20/12 Disturbing his friend

Previous History of Disease

PSYCHIATRY HISTORY Havent been hospitalized before

MEDICAL HISTORY

DM(-) Hypertension(-) Asthma(-) Alergy (-) Seizure history (-) Drugs History (-) Alchoholic (-) Smoking (-)
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DRUGS HISTORY

History of personal life

Prenatal and Perinatal History Early Childhood Phase Intermedia te Childhood Phase Late Childhood Phase No Data

No Data

Patient finished elementary school at 12 y.o, but havent passed the examination. Patient entered Junior High School at 14 y.o after getting Paket B.
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Adulthood Phase

Education : Junior High School Occupation : Unemployed Religion : praying frequently, 5 times/day Military : No data Psikosexual : Patient perform and behave like a man, attracted to women. Frequently masturbated, twice a day Criminal : No data
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Genogram

Normal Man Pati ent Normal Woman

Suici de
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Family History : Patient is the third child from 6 siblings. His younger brother was suicide. His father is unemployed, and always pray all day long. Sosioeconomic History : Patient is unemployed Patients mother is the main support of his family economic life Social interaction is limited
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Level of convidence
Alloanamnesis : untrustable Autoanamnesis : trusted

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Illness progression
sympto m

3 months before admissi on

1 week before admissi on

Role function

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Mental State
A. GENERAL DESCRIPTION APPEARANCE A man, looked like his age He wore a black trousers with white shirt He hasblackhair and his body posture isastenicus Psychiatry Conciousness
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1.

2.

3. behavior

normoactive

q q q q q

Hypoactive
Hyperactive Echoplaxia Catatonia Active negativisme Catoplexi Streotype Mannerism Otomatism

q q q q q q

Command otomatism Acathysia Tic Sonambulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia
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4. attitude

Cooperative
Non-cooperative Indiferrent Apathy Tention Dependent Active Passive

Infantile Distrust Labil Rigid Passive negativism Streotype Catalepsi Cerea flexibility

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5. Psychis contact

easily drawn,easy tobe specified hardly drawn,easy tobe specified hard drawn,hard tobe specified
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B. EMOTION

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C. PERCEPTION DISORDER
Halucinati on

Illusion
Auditoriy Visual Olfactory Gustatory Tactile

Visual

Auditory

Olfactory Gustatory Tactile Somatic Depersonalitation : -

Dereliasitation: 5/20/12

D. Thought process
1. Thought progression
QUANTITY

QUALITY

Logorrea

Remming
Blocking Mutisme Talkactive

coherence
Incoherence
Flight of idea Circumstansiality Poverty of speech neologism Tangensiality Verbigrasi Perseverasi Convabulation 5/20/12 Ecolali

2. Thought content

Idea of reference Preoccupation Obsession Phobia Delusion of suspicious Delusion of envious

Delusion of magic-mistic
Delusion of control Delusion of influence Delusion of passivity Delusion of perception Thought of echo Thought of insertion/withdrawal Thought of broadcasting

Delusion of persecutory
Grandious Delusion

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4. Sensorium & cognition

Educational Knowledge

: lack of educational : good

Orientation w/t/o/s : good/good/good/good immediatememory/short/long : good/good/good/good ability to readandwrite : good Visuospatial ability Abstract thought : cant be evaluated
5/20/12 : can`t beevaluated

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Significant Finding Resume

A man, 22 years old, unemployed Talk to himself Like being alone, got sleep disturbance (initial insomnia), loss of appetite, easily irritated. Attitude : cooperative, behavior : normoactive Mood : dysforic, Affec : appropiate, restrictive 5/20/12

Deterioration :

role function Social function self care

: poor : poor : poor : enough

Sparetime managemet

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Differential Diagnosis

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Multiaxial diagnosis

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TREATMENT
Hospitalized
Farmacotherapy : Haloperidol tab 2x5 mg/day

Familyeduca tion: - Explainto his familyabout the mental disorder of

this patient include the causes. - Describes stepsoftreatment -family must maintain the patients drugs consumption and routine doctor consultation , so it will increase the efficacy of treatment -familiy must keep in touch with patient intensively, so the patient will not feel lonely 5/20/12 - the family shouldnt force the patient to think like a

Prognosis

Ad vitam

: dubia ad malam : dubia ad malam

Ad Sanationum

Ad Fungsionum : dubia ad malam

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For your attention

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