morning report tata

7/30/2019 Morning Report Tata

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Supervisor : Dr. Sabar P. Siregar, Sp. KJ


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I. Patient Identity

Name :

Age :

Sex gender :

Address :

Occupation :Marriage status :

Religion :

Education :

AlloanamnesisName :

Age :

Relation


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II. Psychiatric History

Chief Complaint:


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History of present illnes


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History of present illnes

Psychiatric History

General medical history

Drugs and alcohol abuse history and smoking history


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Life history

Prenatal and perinatal

Early childhood phase (0-3 tahun)

Intermediate childhood phase (3-11tahun)

Late childhood and teenager phase (11-18 tahun)


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Adulthood

Education history

Occupational history

Marriage status

Legal History

Social Activity Current situation Religion history


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Family history

Psychosexual history


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Genogram


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Socio-economy history

ValidityAlloanamnesis :

Autoanamnesis :


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Illnes Progression

Symptom

Role function


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III. MENTAL STATE

Appearance

State of conciousness

Speech : Quality :

Quantity :


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Behaviour

Normoactive

Hypoact ive

Hyperactive

Echoplaxia

Catatonia Active negativism

Cataplexi

Streotype

Mannerism Automatism

Commandautomatism

Mutism

Acathysia

Tic Somnabulism

Psychomotor agitation

Compulsive

Ataxia

Mimicry

Aggresive

Impulsive

Abulia


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Attitude

Cooperat ive

Non-cooperative

Indiferrent

Apathy

Tension

Dependent

Active Passive

Infantile

Distrust

Labile

Rigid

Passive negativism

Stereotypy

Catalepsy Cerea flexibility


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Physic contact

Yes/ No

Suitable/unsuitable

Sustainable/ unsustainable


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Emotions

Mood Afek

Euthymic

Dysphor ic

Euphoria

Elevated

Expansive

Irritable

Appropr ia te

Inappropriate

Restrictive

Blunted

Flat

Labile


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Disturbance of perception

halucination illusion

Auditory (-)

Visual (-)

Olfactory (-)

Gustatory (-) Tactile (-)

Somatic (-)

Depersonalisasi :

Auditory (-)

Visual (-)

Olfactory (-)

Gustatory (-) Tactile (-)

Somatic (-)

Derealisasi :


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Thought processcontent of thought Idea of reference

Hypochondriac

Preoccupation

Obsession

Phobia

Delusion of magic mystic

Delusion of infidelity

Delusion of control Delusion of influence

Delusion of passivity

Delusion of perception

Delusion of persecution

Delusion of grandeur

Delusion of reference

Thought of echo

Thought withdrawal

Thought insertion Thoght broadcasting

Thought control


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E. SENSORIUM and

cognition Level of education : enough

General knowledge : enough

Orientation of people, time, place,

situation: enough Working/short/long memory : no data

Writing and reading skills : no data

Visuospatial : no data

Abstract thinking : enough

Ability to self care : enough


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F. Impulse control

Self control during assessment : Poor

Patient response to examinersquestions : Poor

G. Insight Impaired insight

Intelectual insight

True insight


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IV. Physical examination


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A. Internal status

General state : good

Conciousness : compos mentis

Vital sign:

Blood pressure : 120/80

Pulse rate : 80

Temperature : 36,5C

RR: : 20x/mnt


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Head : normocephali

Eyes anemic conjungtiva -/-, icterik sclera -/-,RCL +/+, RCTL +/+, pupil isocore

Neck : normal, no rigidity

Thoraks:

cor : S1 and S2 sound clear and normal , reguler,murmur - , gallop

Lung: vesicullar sound, wheezing -, ronchi -

Abdomen : slight tenderness (LUQ)

Extremity : acral temperature , capp refill


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B. Neurological status

Motoric : normotonus, good

coordination of movement

Physiological reflex : +/+

Pathological reflex : -/-


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V. Significant finding resume


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Deterioration

Role function : poor

Social function : poor

Sparetime managemet : poor Self care : enough


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Mood : dysphoric

patient looks sad and loses her interest to thingsshe love

Disturbances of Perception

Thought process

Thought progression : quantitative

qualitative

Thought content :

Form of though :


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Differential Diagnosis


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Diagnostic Formulation


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Multiaxial Diagnose

Axis I :

Axis II :

Axis III :

Axis IV :

Axis V :


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Therapy


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Prognosis

Ad vitam : Ad bonam

Ad functionam : Ad bonam

Ad sanationam : Ad bonam

morning report tata

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