Academic presentation for college course (globe design)

Morning reportRSJ Prof. Dr. SoerojoSunday, 22nd March 2015Presentation slide for courses, classes, lectures et al. 1Patients IdentityName : Mr. AAge : 43 yoReligion: Moslem Address : Jagoan, MagelangJob : Parking attendantsMarital status : MarriedEthnicity : JavaneseEducational status : Senior High School (finished)Objectives for instruction and expected results and/or skills developed from learning. 2Alloanamnesis was conducted to :Name : Mrs. NAge : 55 yoRelation : Older SisterAddress : Jagoan, Magelang

Psychiatric historyMorning ReportSunday, 22nd March 2014Presentation slide for courses, classes, lectures et al. 4Chief ComplaintAngry and threaten people with word.StressorUnclear

History of Present Illness1993Although his condition was better, the patient didnt work during 2 years (1991-1993). The guardian (alloanamnesis) said that patient routinely take his medicine during 2 years. However, patient had some odd behaviour again, so that patient was hospitalized (2nd time) in RSJSM for 20 days.1991Patient graduated from senior high school and wanted to continue his education in military academi. Patient passed several test but patient couldnt make it for the final test. Therefore, patient failed to get through in military academi. Since then, patient had some odd behaviour, such he always daydreaming, screamed, and angry. Patient was admitted to the RSJSM for the first time and he had to hospitalized for 20 days.Cont..1995Patient still didnt work during 1993 until 1995. Although patient took his medicine routinely, patient showed some odd behaviour again, therefore patient was admitted to RSJSM (3rd time) and hospitalized for 1 month. 2006Patient still didnt work during 1995 until 2006. He still took his medicine routinely. However, patient was admitted to RSJSM (4th time) for the same reason as before and hospitalized for about 1 month. Since then, he underwent outpatient and took his medicine regularly. Patient had haloperidol, chlorpromazine, and trihexylpenydyl for his treatment2007Patient condition was much better so that patient married a woman and started to work for any jobs (serabutan). Patient still took his medicine and underwent outpatient regularly. 1 months before admissionPatient didnt take his medicine routinely as before. Since then, patient was easy to get angry, talked and laugh by himself when he was alone. Patient still did his job as parking attendants but patient began to have less social activity such worship together (pengajian) or having conversation with some neighbours. Patient still take a bath and eat by himself, he is doing that without command. Patient said that he is angry because he always heard some people always mocking at him and talking about him. He heard that repeatedly when he was conscious and alone. 3 days before admission the symptoms was much worse so that patient could angry and also threaten others that he could kill them. Day of admissionPatient is brought to the hospital by his sister because he just threatens others again that he could kill them and angry without any reason.

He is talking and laughing by himself when he was alone.

He said that he heard some people mocking and talking about him. He heard that repeatedly when he was conscious and alone.

He feels suspicious and also believes that every people is badmouthing behind his back. Day of admissionWhile he is listening the radio, he always feels that the radio broadcast what inside his mind and what he would do next.

He had an excessive affection toward kyai mahmud (a religion leader that give speech on the radio which he listened everyday) so that he believes that he is the right-hand man of kyai mahmud.Cont..Psychiatric illnessNo information showed that patient ever recover since the first episode (1991)General medical illnessThere is history of chronic obstructive pulmonary disease (COPD) which needs inhalation therapy every time he had breathless attackHead trauma (-) Epilepsy (-) Seizures (-)Substance abuseHistory of smoking (one pack per day)NAPZA (-)Alcohol (-)Family HistoryThere is history of psychiatric illness in patients family: patients older sister (Had passed away)There is no history of high fever, seizure, head trauma, or any other serious illness which needs hospitalizationHistory of Personal LifePrenatal & PerinatalHistory of pregnancyPatient is the latest child from six children. The pregnancy was planned.History of birthHe was born normally at home with the help from traditional midwife.

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)Psychomotor (No Valid Data)- There were no valid data on 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 his hand(3-6 months)putting everything in his mouth(3-6 months)

Psychosocial (No Valid Data)- There were no valid data on which age patient 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)

INTERMEDIATE CHILDHOOD PHASE (3-11 YEARS OLD)Psychomotor (NO VALID DATA)No valid data on when patients first time playing hide and seek or if patient ever involved in any kind of sports.Psychosocial (NO VALID DATA)No valid data when patient child and his ability to communicate with other people.Communication (NO VALID DATA)No valid data on Patients ability to make friends at school.Emotional (NO VALID DATA)No valid data on patients emotional.Cognitive (NO VALID DATA)No valid data on patient academic history.

LATE CHILHOOD & TEENAGE PHASESexual development signs & activity (NO VALID DATA) No data when patient wet dream etc.Psychomotor (NO VALID DATA) No valid data on patients favourite hobbies or games, if patient involved in any kind of sports.Psychosocial He is easy to get angry and frustated whenever his wish cannot be fulfilledEmotional (NO VALID DATA) No valid data on patients emotional.Communication (NO VALID DATA) No valid data regarding patient ability to make friends at school and how many friends patient have during his junior high school period

ADULTHOOD Educational HistoryHe was graduated from senior high school.

Occupational historyHe began to work right after he got married. Work for any jobs (serabutan).Marital StatusHe got married at 16 years after the first episode. He had a boy, since then.Criminal History There is no criminal history Social Activity

Current Situation He lives with his wife and childEriksons 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 lifeHistory of Personal LifePatient realizes that she is a maleHas interests to femaleHer attitude is appropriate as a maleGenogramProgression of Illness 1991 1993 1995 2006 2015 SymptomsRole FunctionEXAMINATIONMorning ReportSunday, 22nd March 2014Presentation slide for courses, classes, lectures et al. 23Physical ExaminationGeneral physical examinationGeneral appearance: Good nutritional statusVital sign: BP: 129/80 mmHgHR: 84x/mto: afebrisRR: 20x/m

Saturday, October 25th, 2014Review SystemHead : 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