Morning Report
Morning ReportFriday , October 12th,2012
Supervisor : dr Sabar P Siregar Sp.KjI.Patients IdentityName:
Miss Y.Age: 23 years oldGender: FemaleAddress: Magelang Occupation:
UnemployedMarriage status: SingleReligion: IslamLast education:
Senior High School
AlloanamnesisName: Mr. H. Age : 61 years oldRelation: Patients
father
II.Chief complaintPatient agitated in anger and kept scolding
family members.Presenting illness 10 days agoPatient often gets
agitated in anger and starts scolding family members.Patient often
throws things in anger and slams the door.Patient talks and laughs
to herself. At times, patient cries for no reasonPatient often
locks herself in the room.Patient walks out of her house especially
late at night. Impaired social functions ( always isolates herself
)Deterioration in performing functioning roles, ability to care for
herself.
HISTORY OF PRESENT ILLNESSHistory of Personal LifePRENATAL AND
PERINATAL HISTORYHer mother was perfectly healthy when shes
pregnant. Patient delivered through normal delivery at term by a
midwife
Early Childhood Phase (0-3 Years Old)
(Continue)PsychomotoricNormal growth and development but not enough
information was gathered.PsychosocialWas not asked.Communication
The timing for the patients first words were not known. 7Emotion
Patient showed normal reaction when playing, frightened by
strangers 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.
Intermediate Childhood (3-11 y.o)PsychomotorNo valid data on
when patients first time riding a tricycle or bicycle, if patient
ever involved in any kind of sports.PsychosocialThere were no data
on patients gender identification,CommunicationPatient had many
friends and socialized well.EmotionalNo valid data on patients
adaptation under stressCognitiveSufficient grades and advancement
to next level of class.9Late Childhood & Teenage PhaseSexual
development signs & activityNo valid data on when patients
puberty. Hair on armpits and pubis, etcPsychomotorPatient was an
active scout and a leader.PsychosocialBegin to have less friends
after her illness in SMA IIEmotionalPatient expressed her feelings
widely.CommunicationPatient has communication well with other
people though at times gets easily agitated.
10Family HistoryCurrently the third daughter in the family and
lives with both parents at home.She has two elder sisters and a
younger brother.Her fraternal grandmother was said to have mental
disturbance but of unknown cause.Psychosexual historyPatient
psychosexual history was not assessed.Progression of
IlnesssymptomRole functionFeb 2010March 2010October 2012III Mental
StateAppearance : Young woman, appropriate according to age,
dressed appropriately, with black stains on her pants.State of
ConsciousnessClearSpeech:Quantity : lowQuality : poor
Behaviour HypoactiveHyperactiveEchopraxiaCatatoniaActive
negativismCataplexyStreotypyMannerismAutomatismCommand
automatismAcathysiaTicSomnabulismPsychomotor
agitationCompulsiveAtaxiaMimicryAggresiveImpulsiveAbulia
ATTITUDECooperativeNon-cooperativeIndiferrentApathyTensionDependentActivePassiveInfantileDistrustLabileRigidPassive
negativismStereotypyCatalepsyCerea flexibility
EmotionDisturbance of perceptionDepersonalisation
(-)Derealisation (-)Unable to be assessedUnable to be
assessedThinkingthought progression20Thought Processcontent of
thoughtIdea of referencePreokupasiObsesiFobiaDelution of
persecutionDelution of suspiciousDelution of enviousDelution of
hipokondriDelusion of magic-misticDelusion of controlDelusion of
influenceDelusion of passivityDelusion of perceptionThought of
echoThought of insertion/withdrawalThought of broadcasting
Unable to be assessedThought formForm of Thought
RealisticNon RealisticDereisticAutism
SENSORIUM and cognitionLevel of education: enoughGeneral
knowledge: enoughOrientation of time: enough place: enough people :
enough Working/short/long memory: enoughWriting and reading skills:
evaluatedVisuospatial: enoughAbstract thinking : not
evaluatedAbility to self care: goodIV. PHYSICAL EXAMINATIONInternal
StatusConciousness : compos mentisVital sign:Blood pressure: 120/70
mmHgPulse rate : 82x/mntTemperature : afebrisRR:: 22x/mnt
Head : normocephaliEyes : anemic conjungtiva -/-, icterik sclera
-/-, pupil isocoreNeck : normal, no rigidity, Thorax:Chor : unable
to assessLung : unable to assessAbdomen : unable to assessExtremity
: Warm acral, capp refill
