Tuesday, 30th May 2014

MORNING
REPORT

SUPERVISOR
dr. Sabar P. Siregar, Sp.

Patient Identity
Name
Sex
Age
Address
Occupation
Marital State

:
:
:
:
:
:

Mr. R
Male
25 years old

Grabak, Magelang
Unemployed
Single

RELATIVES IDENTITY

Name : Mr. A
Sex : Male
Age : 57 years old
Relation : Father

Reason patient was brought to

emergency room

Patient did committe suicide,

irrelevance, and unable to sleep

Stressor
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

Present history
Suspect his wife
having an affair with
his neighbor
2013
Feel guilty
Trouble sleeping

His family wasnt

bring the patient
to hospital.

27th May 2014

The patient was

brought to the
ER
th
30 May 2014

Stay alone in his

bedroom,
irrelevance, feel
guilty, committe
suicide, appetite

Day of Admission
30th May 2014
Patient brought with
the complaints of:
Committe suicide
Irrelevance
Wont eat
Unable to sleep

Brought to
hospital by
his father

The patient didnt go to work

Leasurely time is used to daydream only
Appetite
Didnt socialize with his family/others

PSYCHIATRIC HISTORY

No Psychiatric History

General
medical
history

Drugs and
alcohol abuse
history and
smoking history

Head injury (-)

Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)

Drugs consumption (-)

Alcohol consumption (-)
Cigarette Smoking (+)

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

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

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.

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

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.

LATE CHILDHOOD & TEENAGE

PHASE
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

ADULTHOOD

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

Eriksons stages of
psychosocial development
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

FAMILY HISTORY

Patient is the 2rd child of 4

siblings

Psychiatry history in the

family (-)

Genogram

MALE

FEMALE

Patient

PSYCHOSEXUAL
HISTORY
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

Normal
Time Line

Role Function

2013

May 2014

Mental State
30th May 2014

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

Noncooperative
Indiferrent
Apathy
Tension
Dependent
Passive

Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited

Emotion
Affect

Mood

Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed

Inappropriate
Restrictive
Blunted
Flat
Labile

Disturbance of Perception
Hallucination

Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-)

Illusion

Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
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

Delusion of grandiose

Preoccupation

Delusion of Control

Obsession

Delusion of Influence

Phobia

Delusion of Passivity

Delusion of Guilty

Delusion of Perception

Delusion of Persecution

Delusion of Suspicious

Delusion of Reference

Thought of Echo

Delusion of Envious

Thought of Insertion &

Delusion of Hipochondry

Delusion of magic-mystic

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

Insight

Impulse control
when examined
Self control: Enough
Patient response to
examiners question:
Bad

Impaired insight
Intellectual Insight
True Insight

Physical State
Consciousnes
Vital sign :

: compos mentis

Blood pressure
: 130/80 mmHg
Pulse rate
: 120 x/mnt
Temperature
: 36.5 C
RR
: 20 x/mnt

Review System

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

RESUME
Male 25 years old, appropiate to his age, completely
clothed

Mental
Status

Symptoms
Daydream
Mad till
commite
suicide
Unable to
sleep

Behaviour : Hypoactive

- Attitude: Non-Cooperative
- Mood: Dysphoric
-

Affect: Blunted

Form of Thought: Nonrealistic

Content of thought:
Delution of guilty and
suspicious

- Patients response to
question: bad
- Impaired insight

Impairment
The patient
didnt go to
work
Leasurely time
is used to
daydream only
Wont eat
Didnt socialize
with his
family/others

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 Symptom
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

Problem related to the

patient
1. Problem about patients life
The patient had problem with his wife, didnt work
about 3 days. Lives with his parent.
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

PLANNING MANAGEMENT
Inpatient (hospitalization)
To reduce 50% the symptoms :

Mood dysphoric
Feel exhausted
Trouble sleeping
Feeling guilty
Commite suicide

Response

Remissio
n

Recovery

RESPONSE PHASE
Target therapy : 50% decrease of symptoms
Emergency department
Inj Haloperidol 5 mg IM
Inj Diazepam 5 mg IV
Maintanance
Fluoxetine 1x25mg (morning)
Captopril 2x12.5mg
Plan
ECT
Re-assess patient

REMISSION PHASE
Target therapy :
100% remission of symptom
Inpatient management
1. Continue the pharmacotherapy: maintenance
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

RECOVERY PHASE
- 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
Target therapy : 100% remission of
Target therapy : 100% remission of
symptom within 1 year.