MORNING REPORT
SUPERVISOR dr. Sabar P. Siregar, Sp.KJMORNING REPORTTuesday,
30th May 20141Patient IdentityName : Mr. RSex: MaleAge : 25 years
oldAddress : Grabak, MagelangOccupation : UnemployedMarital State:
Single
RELATIVES IDENTITYName: Mr. ASex: MaleAge: 57 years oldRelation:
FatherReason patient was brought to emergency roomPatient did
committe suicide, irrelevance, and unable to sleepStressorPatient
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 GovermentPresent historyThe patient was brought to
the ERHis family wasnt bring the patient to hospital.Stay alone in
his bedroom, irrelevance, feel guilty, committe suicide,
appetiteSuspect his wife having an affair with his neighborFeel
guiltyTrouble sleeping 27th May 201430th May 20142013Day of
Admission30th May 2014Patient brought with the complaints
of:Committe suicideIrrelevanceWont eatUnable to sleepBrought to
hospital by his father
The patient didnt go to workLeasurely time is used to daydream
onlyAppetiteDidnt socialize with his family/othersPSYCHIATRIC
HISTORY No Psychiatric HistoryEARLY 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 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.11INTERMEDIATE 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 periodEmotional No valid
data on patients emotional.CognitiveNo valid data on patients
cognitive.12LATE CHILDHOOD & TEENAGE PHASESexual 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 period13ADULTHOOD Educational Historyfinished 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 SituationHe lives with his parents, family and
sister.14Eriksons 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 lifeFAMILY HISTORYPatient is the 2rd child of
4 siblings
Psychiatry history in the family
(-)16GenogramMALEFEMALEPatientPSYCHOSEXUAL HISTORYPatient realizes
that he is a male, and interests to a female. His attitude is
appropriate as a male.18Progression of DisorderSymptomRole
Function2013May 2014NormalTime LineMental State 30th May
2014BEHAVIOUR HypoactiveHyperactiveEchopraxiaCatatoniaActive
negativismCataplexyStreotypyMannerismAutomatismBizarreCommand
automatismMutismAcathysiaTicSomnabulismPsychomotor
agitationCompulsiveAtaxiaMimicryAggresiveImpulsiveAbulia
-echopraxia : pengulangan gerakan yang sama oleh pasien meniru
gerakan pemeriksa-catatonia : perilaku catatone, mempertahankan
gerakan aneh-active negativisme : tahanan tanpa motivasi untuk
menggerakkan (memberontak, melawan gerakan)-cataplexy : penurunan
tonus otot karena konflik psikologis-stereotypy :
pergerakan/pembicaraan yang terfiksasi dan berulang-ulang-mannerism
: pengulangan gerakan yg tidak disadari dan menjadi
kebiasaan-automatism : tindakan yang otomatis/spontan, biasanya
mewakili aktivitas simbolik yang tidak disadari-bizarre : aneh
-command automatism : melakukan apa yg diperintahkan secara
otomatis-mutism : pasien tidak mau bicara-impulsive : dari keadaan
diam lalu tiba2 melakukan sesuatu yg dia ingin dan langsung
dilakukan22ATTITUDENon-cooperativeIndiferrentApathyTensionDependentPassiveInfantileDistrustLabileRigidPassive
negativismStereotypyCatalepsyCerea flexibilityExcited-excited:
agitated, purposeless motor activity without external
stimuli23EmotionDisturbance of PerceptionDepersonalization
(-)Derealization (-)Thought ProgressionContent of ThoughtIdea of
ReferencePreoccupationObsessionPhobia Delusion of GuiltyDelusion of
PersecutionDelusion of ReferenceDelusion of EnviousDelusion of
HipochondryDelusion of magic-mysticDelusion of grandioseDelusion of
ControlDelusion of InfluenceDelusion of PassivityDelusion of
PerceptionDelusion of SuspiciousThought of EchoThought of Insertion
& withdrawalThought of BroadcastingForm of ThoughtRealisticNon
RealisticDereisticAutismCannot be evaluated
28Sensorium and CognitionLevel of education: finished senior
high schoolGeneral knowledge: GoodOrientation of time :
GoodOrientations of place: BadOrientations of people:
GoodOrientations of situation: GoodWorking/short/long memory: cant
be accessedWriting and reading skills: cant be
accessedVisuospatial: cant be accessedAbstract thinking: cant be
accessedAbility to self care: cant be accessed
Physical StateConsciousnes : compos mentisVital sign :Blood
pressure: 130/80 mmHgPulse rate : 120 x/mntTemperature : 36.5 CRR:
20 x/mntReview SystemHead : normocephali, mouth deviation (-)Eyes :
anemic conjungtiva (-), icteric sclera (-), pupil isocoreNeck :
normal, no rigidity, no palpable lymph nodesThorax:Cor : S 1,2
regularLung : vesicular sound, wheezing -/-, ronchi-/-Abdomen :
Pain (-) , normal peristaltic, tympany sound Extremity : Warm
acral, capp refill
