Wednesday night shift, 17h

September 2014

MORNING
Supervisor
: dr. Sabar P. Siregar,
REPORT
Sp.KJ

Patient Identity
Name
: Mr S
Sex
: Male
Age
: 45 years old
Address
: Magelang
Occupation
: Unemployed
Marital State : Divorced
Education
: Junior High School

RELATIVES IDENTITY

Name : Mrs. Nn
Sex
: Female
Age
: 42 years old
Relation
: Younger sister

Reason patient was brought to

emergency room

Patient had symptoms of uncontrolled

anger, rampage, talking and laughing for
unknown reasons since a week ago

Stressor

His mother didnt give money

Present History
2 months ago

After dischargefrom RSJS 2

months ago with similar
symptoms, he didnt go to
RSJS for therapy. He also
didnt take the medicines
regularly.

He had decreased appetite, talking

and laughing non-sense. He was
still able to socialize and do daily
activities.

Present History
A week ago

Uncontrolled anger,
rampage, more talking and
laughing for unknown reasons.
Patient was said to have stop
taking drugs.

He was not able to do daily

activities and had difficulty in
sleep. He didnt socialize with
others and still had decreased
appetite

PSYCHIATRIC HISTORY
He had been hospitalized for
3 times since 4 years ago

Day of Admission
17th September
2014

Brought to
hospital by
the sister

Patient was brought

because of:
Uncontrolled anger
Rampage
More talking and laughing
for unknown reasons
Patient was said to have
stop taking drugs.

He was not able to do daily

activities and had difficulty
in sleep. He didnt socialize
with others and still had
decreased appetite

EARLY CHILDHOOD PHASE (0-3 YEARS

OLD)

Psychomotoric (No Valid Data)

- there were no valid data on which age patient
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)

Communication (NO VALID DATA)

- there were no valid data on when patient started bubbling. (6-9
months)
Emotion (NO VALID DATA)
- 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 (NO VALID DATA)
- 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)
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)
No valid data on patients emotional.
Cognitive
Patient was one class backward at 2 nd standard of elementary
school.

LATE CHILDHOOD & TEENAGE

PHASE
Sexual development signs & activity
No valid data on patients sexual development
Psychomotor
No data if patient had any
patient involved in any kind of

favourite hobbies or games, if

sports.

Psychosocial
No valid data regarding patient psychosocial.
Emotional history
No valid data on patients emotional history.
Communication
No valid data regarding patient ability to make friends at school
and how many friends patient have during his school period.

ADULTHOOD

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 1st child of 2 siblings.
There is no psychiatry disorder in family
history.

Genogram

Femal
e
Male

Dead
Patient

Divorced
Live in one
house

PSYCHOSEXUAL
HISTORY
Patient realizes that he is male, and has interests to female.
His attitude is appropriate as a male.

Progression of Disorder
Symptom
2010

Role Function

August,
2013

July,
2014

Now

Mental State
17th September 2014

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
Indifferent
Apathy
Tension
Dependent
Passive

Infantile
Distrust
Labile
Rigid
Passive negativism
Catalepsy
Cerea flexibility
Excited

Emotion

Disturbance of Perception

Depersonalization (-)

Derealization (-)

Thought Progression

Content of Thought

Idea of Reference

Delusion of grandiose

Idea of Guilt

Delusion of Control

Preoccupation

Delusion of Influence

Obsession

Delusion of Passivity

Delusion of Persecution

Delusion of Perception

Delusion of Reference

Delusion of Suspicious

Delusion of Envious

Thought of Echo

Delusion of Hipochondry

Thought of Insertion &

Delusion of magic-mystic

withdrawal
Thought of Broadcasting

Form of Thought
Non Realistic
Dereistic
Autistic
Cannot be evaluated

Sensorium and Cognition

Level of education
: Junior high school
General knowledge
: not assessed
Orientation of time
: Good
Orientations of place
: Good
Orientations of people
: Good
Orientations of situation : Good
Working/short/long memory: Not assessed
Writing and reading skills
: Not
assessed
Visuospatial
: Not accessed
Abstract thinking
: Not accessed
Ability to self care
: Poor

Physical State
Consciousnes

: compos mentis

Vital

sign :
Blood pressure
mmHg
Pulse rate
Temperature
RR

: 110/70
:
:
:

86 x/mnt
36.7
18 x/mnt

Review System

Head

: Normocephali, mouth deviation (-)

Eyes

: Anemic (-), icteric (-),

Neck

: No rigidity, no palpable lymph nodes

Thorax

Cor

: S1-S2 reguler, murmur (-)

Lung

: Vesicular sound, wheezing -/-, ronchi-/-

Abdomen : Pain (-) , normal peristaltic sound,

Extremity : Warm ,capillary refill tine <2, edema (-)

Neurological exam : Not examined

RESUME
A man, 45 years old, appropriate according
to his age, completely clothed, poor self care
Reason to be brought to hospital were
Uncontrolled anger, rampage, more talking
and laughing for unknown reasons. Patient
was said to have stop taking drugs.
He was not able to do daily activities and had
difficulty in sleep. He didnt socialize with
others and still had decreased appetite

 Uncontrolle
d anger
Rampage
More
talking and
laughing for
unknown
reasons

Mental
Status

Impairment

-Mood: dysphoric
- Perception: auditoric
hallucination (+)
-Content of Thought : idea
of guilt, delusion of
persecution
- Form of thought: nonrealistic
- Impaired insight

He was not able to

do daily activities
and had difficulty in
sleep. He didnt
socialize with
others and still had
decreased appetite

Differential Diagnosis
F20.0 Paranoid Schizophrenia
F25.2 Schizoaffective mixed-state
type

Multiaxial Diagnosis
Axis I

Axis
Axis
Axis
Axis

: F20.0 Paranoid Schizophrenia

Z91.1 Discontinuation of
medication
II
: Z03.2 No diagnosis
III
: No diagnosis
IV
: Problems with the primary
support group (family)
V
: GAF on admission 30-21

PLANNING
MANAGEMENT
Inpatient (hospitalization)
Patients had Uncontrolled anger, rampage,
more talking and laughing for unknown
reasons. He was not able to do daily
activities and had difficulty in sleep. He
didnt socialize with others and still had
decreased appetite since 1 week ago.

RESPONSE PHASE
Target therapy : 50% decrease of symptoms
Emergency department

Haloperidol
5mg i.m
Diazepam
10 mg i.v (sedative and muscle
relaxant effects)
Maintance
Haloperidol 2x5mg
Re-assess patient

REMISSION PHASE
Target therapy :
100% remission of symptom
Inpatient management
Continue pharmacotherapy: Haloperidol 2x5mg
Improving the patient quality of life :
Teach patient about his social & environment
(interact with his relatives, socialize with his
neighbors, get a new job, find a hobby to do his spare
time)
Outpatient management
1.Pharmacotherapy : Haloperidol 2x5mg
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 and neighbor
Family education :
-Explain to his family about patients mental
disorder and his treatment.
-Educate his family to support not to exile
the patient.
-Ask his family to monitor patients progress
and make sure the patient takes medicine as
prescribed.
Target
therapy : 100% remission of

symptom within 1 year.

THANK
YOU