Morning Luthfi & Kur

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    MORNING REPORT

    SUPERVISOR dr. Sabar P. Siregar, Sp.KJ

    Tuesday , Desember 3rd 2013

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    I. PATIENT’S IDENTITY

    Autoanamnesis Name : Mr. T Age : 40 years o! Gen!er : Mae

    A!!ress : "atang O##u$ation : not %or& Marita status : marrie! 'ast e!u#ation : Eementary S#(oo )not

    gra!uate!*

    Aoanamnesis Name : Mr. A Age : +0 years o!

    Reation : (is ,at(er

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    REASON -Y PATIENT "RO/GT TO OSPITA'

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    STRESSOR

    • 2 years ago he work in sumatra. He wanted to invited his wife and his daughter went to sumatra. But his wife rejected. After that the patient feel bad and Easily get angry 

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    Present History

    Didn’t want to work

    Social withdrawal

     Poor utilization of leisure time

    Didn’t want to work

    Social withdrawal

    Poor utilization of leisure time

    2 year ago 1 Month ago

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    Present History

    Didn’t want to work

    Social withdrawal

     Poor utilization of leisure time

    .

    Didn’t want to work

    Social withdrawal

     Poor utilization of leisure time

    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 $atients gro%t( an! !eeo$ment su#( as:

    • 1rst time i,ting t(e (ea! )23+ mont(s* • roing oer )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 eeryt(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! smiing %(en seeing anot(ers ,a#e )23+ mont(s* • starte! 8y noises)23+ mont(s* • %(en t(e $atient 1rst aug( or suirm %(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 $aying; ,rig(tene! 8y strangers; %(en starting to s(o% 9eaousy or #om$etitieness to%ar!s ot(ers an! toiet training.

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

    $atient #an ,oo% 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 a tri#y#e or 8i#y#e; i, $atient eer inoe! in any &in! o, s$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! on 1rst !ay s#(oo.

    Communication (not get important ata)

    not get im$ortant !ata regar!ing $atient a8iity to ma&e ,rien!s

    at s#(oo an! (o% many ,rien!s $atient (ae !uring (is s#(oo $erio!

    Emotional (not get important ata)

    not get im$ortant !ata on $atient’s a!a$tation un!er stress; any in#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 ,aourite (o88ies or games; i, $atient

    inoe! in any &in! o, s$orts.Psychosocial (not get important ata)  Patient (a! neer 8een to! ,amiy 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! 9eaousy or #om$etitieness Communication (not get important ata)  not get im$ortant !ata on (o% %e t(e reations(i$ 8et%een

    $atient %it( $arent an! (is ,amiy.

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    ADULTHOOD

    Eucational %istory  Eementary s#(oo )not gra!uate!*

    Occupational history    Not %or& reguary

     Marital "tatus  marrie!

    Criminal %istory  No

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

    Current "ituation e ies aone

    Religious history 

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    Erikson’s stages of psychosocial

    development Stage #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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    >amiy (istory

    • Patient is t(e se#on! #(i! o, +

    si8ings.• No $sy#(iatry (istory in t(e ,amiy.

    Family i!"#$y

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    Psychosexual History

    • Patient psychosexual history is appropriate of 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 13 2/12

    o' 13

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

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    ,%ai#*$

    y$oa#tie y$era#tie E#(o$ra=ia

    5atatonia A#tie negatiism 5ata$e=y Streoty$y

    Mannerism Automatism "i

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    ATTITUDE

    C##%$a"i% Non3

    #oo$eratie  In!i,errent A$at(y  Tension

    De$en!ent A#tie  Passie

    In,antie Distrust 'a8ie

    Rigi! Passie negatiism Stereoty$y 5atae$sy

    5erea ?e=i8iity E=#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

    -hobia 7elusion of -ersecution

    7elusion of 6eference

    7elusion of Envious 7elusion 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

    Reaisti# N# R%ali!"i+ Dereisti# Autisti#

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    S%!#$i*m a. C#'i"i#

      'ee 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 : $oor   -riting an! rea!ing s&is : #an’t 8e assese!   isuos$atia : #an’t 8e assese!   A8stra#t t(in&ing : #an’t 8e assese!   A8iity to se, #are : $oor

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