SUPERVISOR

dr. Sabar P. Siregar, Sp.KJ

MORNING REPORT
Tuesday, 30
th
May 2014

Name : Mr. R
Sex : Male
Age : 25 years old
Address : Grabak, Magelang
Occupation : Farmer
Marital State : Married

Name : Mr. A
Sex : Male
Age : 57 years old
Relation : Father
Patient did committe suicide and
unable to sleep
Patient felt he cant do his obligation
as a husband. Patient said his wife
having an affair with his neighbour
and put Talak to his wife.
Guilty to the Goverment
The patient was
brought to the ER
His family wasnt
bring the patient to
hospital.
Stay alone in his
bedroom, feel guilty,
committe suicide,
descreased appetite
Patient suspect his wife
having an affair with his
neighbor
Feel guilty
Trouble sleeping
27
th
May 2014
30
th
May 2014
2013




30
th
May 2014
Patient brought with the
complaints of:
Committe suicide
Unable to sleep

Brought to
hospital by his
father

The patient didnt go to work
Leasurely time is used to daydream only
Decreased appetite
Didnt socialize with his family/others
No Psychiatric History
General
medical history
Head injury (-)
Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)
Drugs and alcohol
abuse history and
smoking history
Drugs consumption (-)
Alcohol consumption (-)
Cigarette Smoking (+)
Psychomotoric
- 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 her hand(3-6 months)
putting everything in her mouth(3-6 months)

Psychosocial
- 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)

Communication
- There were no valid data on when patient started bubbling. (6-9 months)

Emotion
- There were no valid data of patients reaction when playing, frightened
by strangers, when starting to show jealousy or competitiveness
towards other and toilet training.

Cognitive
- There were no valid data on which age the patient can follow objects,
recognizing his mother, recognize his family members.
- There were no valid data on when the patient first copied sounds that
were heard, or understanding simple orders.
Psychomotor
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 regarding patient psychosocial.
Communication
No valid data regarding patient ability to make friends at school and
how many friends patient have during his school period
Emotional
No valid data on patients emotional.
Cognitive
No valid data on patients cognitive.
Sexual development signs & activity
No data on when patient first experience of wet dream, etc.

Psychomotor
No data if patient had any favourite hobbies or games, if patient involved in
any kind of sports.

Psychosocial
No valid data regarding patient psychosocial.

Emotional
No valid data on patients emotional.

Communication
No valid data regarding patient ability to make friends at school and how
many friends patient have during his high school period
Educational History
finished Junior high school

Occupational history
He was a farmer. He didnt
work about 3 days, because
he feel exhausted to go to
work.

Marital Status
He has married

Criminal History
KDRT



Social Activity
He was quite boy and had
many friends

Current Situation
He lives with his parents,
family and sister.
Stage Basic Conflict Important Events
Infancy
(birth to 18 months)
Trust vs mistrust Feeding
Early childhood
(2-3 years)
Autonomy vs shame and
doubt
Toilet training
Preschool
(3-5 years)
Initiative vs guilt Exploration
School age
(6-11 years)
Industry vs inferiority School
Adolescence
(12-18 years)
Identity vs role confusion Social relationships
Young Adulthood
(19-40 years)
Intimacy vs isolation Relationship
Middle adulthood
(40-65 years)
Generativity vs stagnation Work and parenthood
Maturity
(65- death)
Ego integrity vs despair Reflection on life
Patient is the 2
rd
child of 4 siblings

Psychiatry history in the family (+)
Patients cousin
Genogram
MALE FEMALE Patient
Patient realizes that he is a male, and interests to a female.
His attitude is appropriate as a male.
Socio-economic history
Economic scale : low
Validity
Alloanamnesis: valid
Autoanamnesis: valid
Progression of Disorder
Symptom
Role Function
2013 May 2014
Normal
Time Line
Appearance
A male, appropriate to his age, completely clothed
State of Consciousness
Cloudly
Speech
Quantity : Decreased
Quality : Decreased
BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizarre
Command automatism
Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia
ATTITUDE
Non-cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited
Emotion
Mood
Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed
Affect
Inappropriate
Restrictive
Blunted
Flat
Labile
Disturbance of Perception
Hallucination
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-) Derealization (-)
Thought Progression
Quantity

Logorrhea
Blocking
Remming
Mutism
Talk active
Quality
Irrelevant answer
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigration
Perseveration
Sound association
Word salad
Echolalia
Content of Thought
Idea of Reference
Preoccupation
Obsession
Phobia
Delusion of Guilty
Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hipochondry
Delusion of magic-mystic
Delusion of grandiose
Delusion of Control
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Delusion of Suspicious
Thought of Echo
Thought of Insertion &
withdrawal
Thought of Broadcasting
Form of Thought
Realistic
Non Realistic
Dereistic
Autism
Cannot be evaluated

Sensorium and Cognition
Level of education : finished senior high
school
General knowledge : Good
Orientation of time : Good
Orientations of place : Bad
Orientations of people : Good
Orientations of situation : Good
Working/short/long memory: cant be accessed
Writing and reading skills : cant be accessed
Visuospatial : cant be accessed
Abstract thinking : cant be accessed
Ability to self care : cant be accessed

Impulse control when
examined

Self control: Enough
Patient response to
examiners question:
Bad
Insight

Impaired insight
Intellectual Insight
True Insight
Physical State
Consciousnes : compos mentis
Vital sign :
Blood pressure : 130/80 mmHg
Pulse rate : 120 x/mnt
Temperature : 36.5 C
RR : 20 x/mnt
Head : normocephali, mouth deviation (-)
Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax:
Cor : S 1,2 regular
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill <2, motoric strength
Symptoms Mental Status
Impairment


- Behaviour : Hypoactive
-Attitude: Non-Cooperative
- Mood: Dysphoric
- Affect: Blunted
- Form of Thought: Non-realistic
- Content of thought: Delution of
guilty and suspicious
-Patients response to question: bad
- Impaired insight


Daydream

Mad till
commite suicide

Unable to sleep
The patient didnt
go to work

Leasurely time is
used to daydream
only

Wont eat

Didnt socialize
with his
family/others
Male 25 years old, appropiate to his age, completely clothed
Differential Diagnosis
F25.1 Schizoafektif Disorder Depresif Type
F32.3 Severe Depresif Episode with
Psychotic Symptom
Multiaxial Diagnosis
Axis I : F32.3 Severe Depresif Episode with
Psychotic Symptoms
Axis II : F60.1 Schizoid Personality Disorders
Axis III : Prehipertension
Axis IV : Patient felt he cant do his obligation
as a husband. Patient said his wife
having an affair with other man and
put Talak to his wife.
Guilty to the Goverment
Axis V : GAF admission 20-11

1. Problem about patients life
The patient had problem with his wife, didnt work about 3
days. Live in parents house and live with his parents.

2. Problem about patients biological state
In depresif patient, there is abnormal balancing of the
neurotransmitter (serotonin) which has the contribution for
the depresif symptoms. We need pharmacotherapy to
rebalance the neurotransmitter

Inpatient (hospitalization)
To reduce 50% the symptoms :
Mood dysphoric
Stay alone
Feel exhausted
Trouble sleeping
Feeling guilty
Decreased appetite
Commite suicide
Delusion of guilty and suspicious
Response Remission Recovery
Target therapy : 50% decrease of symptoms
Emergency department
Inj Haloperidol 5 mg IM
Inj Diazepam 5 mg IV

Maintanance
Haloperidol 2x5mg
Fluoxetine 1x25mg (morning)
Captopril 2x12.5mg

Plan
ECT

Re-assess patient
Target therapy :
100% remission of symptom

Inpatient management
1. Continue the pharmacotherapy: maintenance Haloperidol
2x5mg, Fluoxetine 1x25mg (morning), Captopril 2x12.5mg
2. Improving the patient quality of life :
Teach patient about his social & environment
(interact with his family, socialize with his neighbor or friends,
find a hobby to do on his spare time)

Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy
Target therapy : 100% remission of symptom within
1 year.
- Continue the medication, control to
psychiatric
- Rehabilitation : help patient to find a
hobby, help patient to interact normally with
his family, his friends and neighbor
- Family education such as tell his family
about patient condition and how much
familly support affect the success of
therapy