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MORNINGREPORTThursday, March 19th 2015Night shiftSupervisor:dr. Sabar P. Siregar, Sp. KJ.Patients IdentityName: Mr. SAge: 31 years oldGender: MaleAddress: Tegal Sari, PurworejoOccupation: UnemployedMarriage Status : MarriedReligion : MoslemLast Education : Elementary School

AlloanamnesisGuardian IdentityName: Mr. JAge: 40 years oldRelation: Brother in lawThe reason patient was brought to the hospitalPatient was brought to the hospital by his brother because he was angry and rampage without any reason. He slamed the door and window, repeatedly.StressorunclearProgression of IllnessThree day before admission The patient seen talk by himself when he was alone, always daydreaming, sometime he was crying without any reason in the bathroom, he was collecting some of sandals around his neighbourhood, he stopped the car and motorcyle but he didnt ride on it and just talked irrelevant sentences beli pasir....The Patient began to stop work because he had some weird behaviour.Therefore, he was sent to his home by his friend.

19th March 2015 (day of admission)The patient angry and rampage without any reasonhe slamed the door and window, repeatedly, he destroyed some households.He was seen talk by himself when he was alone, had rigid behaviour, opened his eyes widely, scratched the soil repeatedly, talked by himself when he was aloneHe feel suspicious to all of peopleHe hear bird sound when he was concious, although there is no definite source of it.He also hears someone whisp that said to him sendal...baju...topi...kaos. He hears it in a concsious state and there is nobody around him that whisp such like that.He cant eat by himselfHe didnt take a bath all day.

History of Past IllnessPsychiatric IllnessThere is no history of psychiatric illness

General Medical IllnessThere is no history of high fever, seizure, head trauma, or any other serious illness which needs hospitalization

Substance AbuseHistory of smoking (one pack per day)No history of use of drugs

Family HistoryThere is no history of psychiatric illness in his family

There is no history of high fever, seizure, head trauma, or any other serious illness which needs hospitalization.

Progression of IllnessRole of FunctionSymptom 2013March 2015GENOGRAMEARLY CHILDHOOD PHASE (0-3 YEARS OLD)Psychomotoric (No Data) Patients growth and development such as:First time lifting the head (3-6 months)Rolling over (3-6 months)Sitting (6-9 months)Crawling (6-9 months)Standing (6-9 months)Walking-running (9-12 months) Holding objects in her hand(3-6 months)Putting everything in her mouth(3-6 months)

Psychosocial (No Data) There are patiens psychosocial such as:Started smiling when seeing another face (3-6 months)Startled by noises(3-6 months)When the patient first laugh or squirm when asked to play, nor playing claps with others (6-9 months)Communication (No Data) Patient started saying bubling word (6-9 months).

Emotion (No Data)Patient had reaction when playing, frightened by strangers, when starting to show jealousy or competitiveness towards other and toilet training.

Cognitive (No Data) The patient can follow objects, recognizing her mother, recognize her family members.The patient first copied sounds that were heard, or understanding simple orders.14INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)Psychomotor (No Data) Patients first time riding a tricycle or bicycle, if patient ever involved in any kind of sports.Psychosocial (No Data) Patient interaction with patients surrounding, no valid data on when patient first entered primary school, on how well patient handle seperation from parents, how well he play with his new friend on first day school.Communication (No Data) Patient ability to make friends at school and how many friends patient has during his school period.Emotional (No Data)Patients adaptation under stress, any incidents of bedwetting were not known.CognitivePatients study from primary school on 6th years old until junior high school. Patient got bad grade at grade 4th and need to repeat his grade.15LATE CHILDHOOD & TEENAGE PHASESexual development signs & activity (No Data) No data on when patient experience Wet Dream, hair on armpits and pubis, etcPsychomotor (No Data) No data about patient hobbies.Psychosocial (No Data) Patient had told the parent about patient friend.Emotional (No Data) No valid data on patients reaction on playing, scared, showed jealously or competitivenessCommunication (No Data) The relationship between patient with parents and other family is goodPsychomotor : jangan lupa diganti karena yang dibuat PPT ini sesuai pasien Ms. Af16Eriksons 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 lifeSosio-Economic HistoryEconomic scale is low, the patient is a construction workers.

ValidityAlloanamnesis: Valid DataAutoanamnesis: Valid DataPhysical Examination (March 19th 2015)General Appearance: bad self grooming.State of ConsciousnessNeurological: (compos mentis)Psychological: ImpairedSocial: ImpairedVital sign: BP: 130/70 mmHgHR:112 x/mto: 36,5 CRR: 24 x/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