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SUPERVISOR

dr. Sabar P. Siregar, Sp.KJ

MORNING REPORT

Tuesday, 30thMay 2014

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Name : Mr. R Sex : Male

Age : 25years old Address :Grabak, Magelang Occupation : Farmer

Marital State : Married

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Name : Mr. A

Sex : Male

Age : 57 years old

Relation : Father

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Patient did committe suicide andunable to sleep

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Patient felt he cant do his obligation

as a husband. Patient said his wifehaving an affair with his neighbourand put Talak to his wife.

Guilty to the Goverment

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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

27thMay 2014

30thMay 2014

2013

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30thMay 2014

Patient brought with the

complaints of:

Committe suicideUnable 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

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No Psychiatric History

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Generalmedical history

Head injury (-)

Hypertension (-)

Convulsion (-)Asthma (-)

Allergy (-)

Drugs and alcohol

abuse history andsmoking history

Drugs consumption (-)

Alcohol consumption (-)

Cigarette Smoking (+)

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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)

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Communication

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

Emotion

- There were no valid data of patientsreaction 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.

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Psychomotor

No valid data on when patientsfirst time playing hide and seek or ifpatient 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 patientsemotional.Cognitive

No valid data on patientscognitive.

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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 patientsemotional.

Communication

No valid data regarding patient ability to make friends at school and how

many friends patient have during his high school period

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Educational Historyfinished Junior high school

Occupational history

He was a farmer. He didntwork 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 hadmany friends

Current Situation

He lives with his parents,

family and sister.

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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

Maturity65- death

Ego integrity vs despair Reflection on life

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Patient is the 2rdchild of 4 siblings

Psychiatry history in the family (+) Patients cousin

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Genogram

MALE FEMALE Patient

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Patient realizes that he is a male, and interests to a female.

His attitude is appropriate as a male.

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Socio-economic history

Economic scale : low

Validity

Alloanamnesis: valid

Autoanamnesis: valid

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Progression of Disorder

Symptom

Role Function

2013 May 2014Normal

Time Line

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Appearance

A male, appropriate to his age, completely clothed

State of Consciousness

Cloudly

Speech

Quantity : Decreased

Quality : Decreased

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BEHAVIOUR

Hypoactive

Hyperactive

Echopraxia

CatatoniaActive negativism

Cataplexy

Streotypy

Mannerism

AutomatismBizarre

Command automatism

Mutism

Acathysia

Tic

SomnabulismPsychomotor agitation

Compulsive

Ataxia

MimicryAggresive

Impulsive

Abulia

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ATTITUDE

Non-cooperative

Indiferrent

Apathy

Tension Dependent

Passive

InfantileDistrust

Labile

Rigid

Passive negativism

Stereotypy

Catalepsy

Cerea flexibilityExcited

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Emotion

Mood

Dysphoric

Euthymic

Elevated

Euphoria

Expansive Irritable

Agitation

Cant be assesed

Affect

Inappropriate

Restrictive Blunted

Flat

Labile

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Disturbance of Perception

Hallucination

Auditory (-) Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-) Somatic (-)

Illusion

Auditory (-) Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-) Somatic (-)

Depersonalization (-) Derealization (-)

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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

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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

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Form of Thought

RealisticNon Realistic

DereisticAutism

Cannot be evaluated

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Sensorium and Cognition

Level of education : finished senior highschool

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

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Impulse control whenexamined

Self control: Enough

Patient response toexaminers question:

Bad

Insight

Impaired insight

Intellectual Insight

True Insight

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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

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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

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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

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Differential Diagnosis

F25.1 Schizoafektif Disorder Depresif Type

F32.3 Severe Depresif Episode with

Psychotic Symptom

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Multiaxial Diagnosis

Axis I : F32.3 Severe Depresif Episode withPsychotic 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

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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 stateIn 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

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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

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Target therapy : 50% decrease of symptomsEmergency department

Inj Haloperidol 5 mg IM

Inj Diazepam 5 mg IV

MaintananceHaloperidol 2x5mg

Fluoxetine 1x25mg (morning)

Captopril 2x12.5mg

Plan

ECT

Re-assess patient

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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

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Target therapy : 100% remission of symptom within

1 year.

- Continue the medication, control topsychiatric

- 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 oftherapy

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