Morning Report

Friday January 9th , 2015Morning ReportPatients IdentityName : Mrs. NAge : 46 years oldSex : femaleAddress : Kejajar WonosoboJob : FarmerMarital status : marriedEthnicity : JavaneseEducational status : Elementary SchoolIdentityAlloanamnesis was conducted to :Name : Mrs. BAge : 25 years oldSex : femaleAddress : Kejajar WonosoboJob : HousewifeMarital status : marriedEthnicity : JavaneseEducational status : Elementary School

Chief ComplaintStrange behaviorHistory of Present Illness5 months before patients admissionPatient locked herself in her room, refuses to talk. She only eats a little food, Isolate herself, rarely taking bath, refuses to do everything. She looks scared, sad, and anxious. At september, her family already took her to Puskesmas and RSUD Wonosobo but the doctor said that there is no significant illness, just too much stressor.She rarely work in the ricefield, limiting his socialication with family and neighbour.

History of Present Illness1 month before patients admissionPatient often talk to herself, gigling, sometimes cannot fall asleep, standing all night long in the front of door because she is forbade to go out by her family. Strated to talk incoherently. Defecating and urinating on the spot. She has to be insisted to take a bath. Wandering inside the house. Eat excessively, but need to be prepared. Crying when she didnt get what she wanted. The day of admissionHer family concerned with her condition and brought him to RSJ Soeroyo Magelang. History of Past IllnessPsychiatric illness There is no history of pcychiatric illness.General medical illnessThere is no history of high fever, seizure, head trauma, or any other serious illness which needs hospitalizationSubstance abuseThere is no history about alcohol use or smoking .

Depiction of IllnessSymptomsRole FunctionAugust 2014January 2015Family HistoryThere is no history of psychiatric illness in her family.There is no history of high fever, seizure, head trauma, or any other serious illness which needs hospitalizationGENOGRAMHistory of Personal LifePrenatal and perinatalThere was no valid data in patients prenatal and perinatal aspect, such as :Patients mothers age and condition when she was pregnantPatients mothers delivery history and patients perinatal condition. Patients immunization status

History of Personal LifeEarly childhood phase (0-3 years old)PsychomotorThere was no valid data in patients psychomotor aspect (such as tilting the body, supine to prone, sitting, standing, walking, smiling, holding her own hand, scoop up object, holding pencil and pilling up two objects)PsychosocialThere was no valid data in patients psychosocial aspect (such as replying to smile, smiling when seeing interesting object, playing cilukba, knowing her family members and pointing what she wanted without crying)CommunicationThere was no valid data in patients communication aspect (such as bubbling, cooing, making sounds without meaning, telling 2-3 syllables without meaning and calling mama/papa)EmotionThere no valid data in patients emotion aspect (such as when patient playing, frightened by strangers, starting to show jealousy or competitiveness towards other, and toilet training)Patient didnt pee or defecate in her pants when she was two years oldCognitiveThere was no valid data in patients cognitive aspect (such as copying sounds that she heard for the first time and understanding simple orders)History of Personal LifeIntermediate childhood phase (3-11 years old)PsychomotorNo valid data on when patients first time playing hide and seek or if patient ever involved in any kind of sports.PsychosocialNo valid dataCommunicationNo valid dataEmotionNo valid dataCognitiveNo valid data. History of Personal LifeLate childhood and teenage phase (11-18 years old)PsychomotorNo valid data if patient had any favorite hobbies or games, if patient involved in any kind of sports.PsychosocialNo valid dataCommunicationPatient didnt have any trouble to communicate with others (such as introducing herself and talking with others)EmotionNo valid dataCognitiveAfter graduating from elementary school, patient did not go to school anymoreHistory of Personal LifeAdulthood phase (18 years old-now)EducationalPatient graduated from elementary schoolOccupationalPatient had work ricefieldMarital statusPatient has got married.CriminalHe has no criminal historySocial activityPatient was an a ricefield and a housewife so she just stayed at home and taking care of her children. Patient sometime interacted with neighbourCurrent situationPatient lives with her husband and 3 children.History of Personal LifePsychosexual history and sexual developmentPatient had menstruation when she was 11 years oldPatient realizes that she is a girl, and interested in male. Her attitude is appropriate as a girl.Patient was taught to be a girl and played with her friendsSocioeconomic historyPatient doesnt have any job nowEconomic scale : lowDegree of validity : validEriksons stages of psychosocial developmentStageBasic ConflictImportant EventsInfancy(birth to 18 months)Trust vs mistrustFeeding Early childhood(2-3 years)Autonomy vs shame and doubtToilet trainingPreschool(3-5 years)Initiative vs guiltExplorationSchool age(6-11 years)Industry vs inferioritySchoolAdolescence(12-18 years)Identity vs role confusionSocial relationshipsYoung Adulthood(19-40 years)Intimacy vs isolationRelationshipMiddle adulthood(40-65 years)Generativity vs stagnationWork and parenthoodMaturity(65- death)Ego integrity vs despairReflection on lifeExaminationMorning ReportThursday January 8th , 2015Physical ExaminationMorning ReportThursday January 8th , 2015

General physical examinationGeneral appearance: She looks in mild illnessVital sign: BP: 120/70 mmHgHR: 100x/mto: afebrisRR: 20x/mGeneral physical examinationHead : normocephali, mouth deviation (-)anemic conjungtiva (-), icteric sclera (-), pupil isocoreNeck : normal, no rigidity, no palpable lymph nodesThorax:Cor : S1 S2 regular, murmur -, gallop Lung : vesicular sound +/+, wheezing -/-, ronchi-/-Abdomen : flat, abdominal wall//chest wall, normal peristaltic, tympany sound, tenderness -, mass -, liver, spleen and kidney not papableExtremity : Warm acral, capp refill