morning luthfi & kur

8/19/2019 Morning Luthfi & Kur

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MORNING REPORT

SUPERVISORdr. Sabar P. Siregar, Sp.KJ

Tuesday , Desember 3rd 2013


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I. PATIENT’S IDENTITY

AutoanamnesisName : Mr. TAge : 40 years o!Gen!er : Mae

A!!ress : "atangO##u$ation : not %or&Marita status : marrie!'ast e!u#ation : Eementary S#(oo )not

gra!uate!*

AoanamnesisName : Mr. AAge : +0 years o!

Reation : (is ,at(er


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REASON -Y PATIENT"RO/GT TO OSPITA'


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STRESSOR

• 2 years ago he work in sumatra. He wanted toinvited his wife and his daughter went tosumatra. But his wife rejected. After that thepatient feel bad and Easily get angry


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Present History

Didn’t want to work

Social withdrawal

Poor utilization of leisure time


Social withdrawal


2 year ago 1 Month ago


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Present History


Social withdrawal


.


Social withdrawal


3 days ago

ay o!ad"ission


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EARLY CHILDHOOD PHASE (0-3 YEARSOLD)

Psychomotoric (NOT GET IMPORTANT DATA)• T(ere %ere not get im$ortant !ata on $atients gro%t( an! !eeo$ment su#( as:

• 1rst time i,ting t(e (ea! )23+ mont(s*• roing oer )23+ mont(s*• Sitting )+3 mont(s*• 5ra%ing )+3 mont(s*• Stan!ing )+3 mont(s*

• %a&ing3running )367 mont(s*• (o!ing o89e#ts in (is (an!)23+ mont(s*• $utting eeryt(ing in (is mout()23+ mont(s*

Psychosocial (NOT GET IMPORTANT DATA)• T(ere %ere not get im$ortant !ata on %(i#( age $atient

• starte! smiing %(en seeing anot(ers ,a#e )23+ mont(s*• starte! 8y noises)23+ mont(s*• %(en t(e $atient 1rst aug( or suirm %(en as&e! to $ay; nor

$aying #a$s %it( ot(ers )+3 mont(s*

Communication (NOT GET IMPORTANT DATA)

• T(ere %ere not get im$ortant !ata on %(en patient started saying words year like !mom"or !dad". #$%& months'


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Emotion (not get important ata) T(ere %ere not get im$ortant !ata o, $atient’s rea#tion

%(en $aying; ,rig(tene! 8y strangers; %(en starting tos(o% 9eaousy or #om$etitieness to%ar!s ot(ers an! toiettraining.

Cogniti!e (not get important ata) T(ere %ere not get im$ortant !ata on %(i#( age t(e

$atient #an ,oo% o89e#ts; re#ogni


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INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor (not get important ata)

not get im$ortant !ata on %(en $atient’s 1rst time ri!ing atri#y#e or 8i#y#e; i, $atient eer inoe! in any &in! o, s$orts.

Psychosocial (not get important ata)

not get im$ortant !ata on $atient intera#tion %it( (is

surroun!ing; not get im$ortant !ata on %(en $atient 1rstentere! $rimary s#(oo; (o% %e (e $ay %it( (is ne% ,rien! on1rst !ay s#(oo.

Communication (not get important ata)

not get im$ortant !ata regar!ing $atient a8iity to ma&e ,rien!s

at s#(oo an! (o% many ,rien!s $atient (ae !uring (is s#(oo$erio!

Emotional (not get important ata)

not get im$ortant !ata on $atient’s a!a$tation un!er stress; anyin#i!ents o, 8e!%etting %ere not &no%n.

Cogniti!e (not get important ata)


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LATE CHILDHOOD & TEENAGE PHASE

"e#ual e!elopment signs $ acti!ity (not get important ata) No !ata on %(en $atient e=$erien#e %et !ream; (air on

arm$its an! $u8is; et#Psychomotor (not get important ata) No !ata i, $atient (a! any ,aourite (o88ies or games; i, $atient

inoe! in any &in! o, s$orts.Psychosocial (not get important ata) Patient (a! neer 8een to! ,amiy a8out $atient’s ,rien!.

Emotional (not get important ata) not get im$ortant !ata on $atients rea#tion on $aying; s#are!;

s(o%e! 9eaousy or #om$etitienessCommunication (not get important ata) not get im$ortant !ata on (o% %e t(e reations(i$ 8et%een

$atient %it( $arent an! (is ,amiy.


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ADULTHOOD

Eucational %istory Eementary s#(oo )not gra!uate!*

Occupational history Not %or& reguary

Marital "tatus marrie!

Criminal %istory No

"ocial Acti!ity a8norma; %it(!ra%a ,rom so#iety

Current "ituatione ies aone

Religious history


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Erikson’s stages of psychosocial

developmentStage #asi$ %on!&i$t I"portant E'ents

(nfancy #birth to ) months'

*rust vs mistrust +eeding

Early childhood#2%, years'

Autonomy vs shame and doubt *oilet training

-reschool#,% years'

(nitiative vs guilt E/ploration

0chool age#$% years'

(ndustry vs inferiority 0chool

Adolescence

#2%) years'

(dentity vs role confusion 0ocial relationships

(o)ng *d)&thood+1-/ years0

Inti"a$y 's iso&ation Re&ationship

1iddle adulthood#3%$ years'

4enerativity vs stagnation 5ork and parenthood

1aturity #$% death' Ego integrity vs despair 6eflection on life


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>amiy (istory

• Patient is t(e se#on! #(i! o, +

si8ings.• No $sy#(iatry (istory in t(e ,amiy.

Family i!"#$y


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Psychosexual History

• Patient psychosexual history is appropriateof his gender and attracted to woman.


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G%#'$am


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Progression o, !isor!er

Sym"#m

R#l% *+"i#

3 des 132/12

o' 13


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Menta State)tues!ay; 2t( !esem8er 7062*


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,%ai#*$

y$oa#tiey$era#tieE#(o$ra=ia

5atatoniaA#tie negatiism5ata$e=yStreoty$y

MannerismAutomatism"i


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ATTITUDE

C##%$a"i%Non3

#oo$eratie In!i,errentA$at(y Tension

De$en!entA#tie Passie

In,antieDistrust'a8ie

Rigi!Passie negatiismStereoty$y5atae$sy

5erea ?e=i8iityE=#itement


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Emotion


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Distur8an#e o, $er#e$tion

7epersonalisation #%' 7erealisation #%'


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T(oug(t $rogression


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5ontent o, t(oug(t

(dea of 6eference

-reoccupation

8bsession

-hobia7elusion of -ersecution

7elusion of 6eference

7elusion of Envious7elusion of Hipochondry

e&)sion o! "agi$-"ysti$

e&)sion o! grandiose

7elusion of 9ontrol

7elusion of (nfluence

7elusion of -assivity

7elusion of -erception

7elusion of 0uspicious

*hought of Echo

*hought of

(nsertion:withdrawal

*hought of Broadcasting


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>orm o, T(oug(t

Reaisti#N# R%ali!"i+Dereisti#Autisti#


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S%!#$i*m a. C#'i"i#

'ee o, e!u#ation : $oor Genera &no%e!ge : $oor Orientation o, time@$a#e@$eo$e@situation:

goo!@goo!@goo!@goo! -or&ing@s(ort@ong memory : $oor -riting an! rea!ing s&is : #an’t 8e assese! isuos$atia : #an’t 8e assese! A8stra#t t(in&ing : #an’t 8e assese! A8iity to se, #are : $oor


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I"%$al S"a"*!

5on#iousnes : #om$os mentisita sign :

◦ "oo! $ressure : 640@600 mmg

◦ Puse rate : B0 =@mnt

◦ Tem$erature : a,e8ris

◦ RR : 70 =@mnt


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H%a. / #$m#+%ali

Ey%! / a%mi+ +#*'"ia --2 i+"%$i+ !+l%$a --2

*il i!#+#$%

N%+ / #$mal2 # $i'i.i"y2 # ala4l% lym #.%!

T#$a5/

C#$ / S 126 S#*. a. #$mal

L*' / %!i+*la$ !#*.2 7%%8i' --2 $#+i--

A4.#m% / Pai (-) 2 #$mal %$i!"al"i+2 "ymay

!#*.

E5"$%mi"y / 9a$m a+$al2 +a $%:ll ;6<


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Neuroogi#a e=am :

• 1otoric; :>= *riceps >:>= ?-6 >:>

• -athological refle/;

Hoffman%*romer %:%= Babinski %:%=9haddock %:%=

6E0@1E


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6E0@1E8nset ; 2 year ago


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DiCerentia Diagnose

• +23.3 -aranoid schiophrenia

• +23. depression post schiophrenia


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M*l"ia5ial Dia'#!%

A/is ( ; +23.3 -aranoid schiophrenia

A/is (( ; 6$.) delayed diagnosis of a/is ((

A/is ((( ; hypertension grade

A/is ( ; primary support group problem #family' A/is ; 4A+ admission 23%

PLANNING


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PLANNINGMANAGEMENT

Hospitaliation

% 6ecover the symptomsC *o establish an effective association between

patients and community support systemsC Hospital treatment plans should be oriented toward

practical issues of self%care= Duality of life=employment= and social relationships


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PLANNING MANAGEMENT

P(arma#ot(isa$y

OEmergen#y t(era$yO Dia


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PROGNOSIS Ad vitam ; dubia ad bonam

Ad functionum ; ad bonam

Ad sanationum ; ad malam


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Ta Y#*=

morning luthfi & kur

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