sunday night shift, 21th September

2014

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

PATIENTs IDENTITY
Name
Sex
Age
Address
Occupation
Marital State

: Mrs.T
: Male
: 46 years old
: Magelang
: Construction Worker
: Married

RELATIVEs
IDENTITY
Name
:
Sex
:
Age
:
old
Relation :

Mr.I
Male
35 years
Wife

Reason patient was brought to

emergency room

Patient had symptoms of uncontrolled anger, solve the window of his

neighbor and takes Parang then said want to kill his neighbor
Rampage, talking and laughing for unknown reasons, Lack of sleep,
Wandering around, since 3 week ago

STRESSOR

He fight with his father in

law and
didnt take the medicines
regulary

PRESENT HISTORY
3 years ago
May 2012
Easily to get
angry
Suspicious
to others
Because
fight with
father in law

Patient
brought to
RSJ
Magelang
then
hospitalized
for a month

The symptom
decreased,
patient could
work as usual

PRESENT HISTORY
2 Years Ago
(March 2013)
Patient easily
to
get
anger
again he want to
strangle her wife

Distrubing
others
Talked
by
herself
He didnt take
the
Rampage
medicines
regularly

Patient brought
to RSJ
Magelang then
hospitalized for
a month

PRESENT HISTORY
2 weeks ago

6 month
ago
He fight
with his
father in
law and
didnt take
the
medicines
regulary

Patient easily to
get anger again
Distrubing
his
neighbour
and
others
Talked
by
herself
Rampage
Lack of sleep

Wandering
around

DAY OF ADMISSION
21th

September 2014

Brought to
hospital by his
wife

Easily angry
Talked by herself
Lack of sleep
He solve the window
by him neighboar and
take parang to killing
him
Suspicious his wife
have affarair
Wandering around
His self care is poor

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
No valid data on patients cognitive.

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
Educational History
he graduated in
elementary school
and did not continue
his study to junior
high school
Occupational history
He is a Construction
Worker
Marital status is
Married

Criminal History
No criminal history
Social Activity
He is an extrovert
person and has a
lot of friends.
Current Situation
He lives with wife
and 2 children but
when he rampage
he live with his
sister

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
The patient is the 2nd and has a 3 siblings
Psychiatry history in the family (-)

GENOGRAM

Femal
e
Male

Dead
Patient

Divorced
Live in one
house

PSYCHOSEXUAL
HISTORY
Patient realizes that he is
male
Has interests to male
His attitude is appropriate as
a male

Progression of Disorder
Symptom
May,
2012

Role Function

March,
2013

Now

Mental State
21th 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
: Elementary school
General knowledge
: not assessed
Orientation of time
: Bad
Orientations of place
: Good
Orientations of people
: Bad
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

: 110/80
:
:
:

91 x/mnt
36.5
18 x/mnt

REVIEW SYSTEM

Head

: normocephali, mouth deviation (-)

Eyes

: anemic conjungtiva (-), icteric sclera (-), pupil

isocore

Neck

Thorax

: normal, no rigidity, no palpable lymph nodes

Cor

: S 1,2 regular

Lung

: vesicular sound, wheezing -/-, ronchi-/-

Abdomen : Pain (-) , normal peristaltic, tympany sound

Extremity : Warm acral, capp refill <2

Neurological exam : not examined

RESUME
A man, 48 years old, appropriate
according to his age
Reason to be brought to hospital are:
Easily angry
Talked by herself
Lack of sleep
Suspicious
Wandering around

Mental
Status

Lack of
sleep
Talked by
herself
Easily get
angry
Suspicious
Wandering
around

-Mood: Disforik
- Perception: auditoric
hallucination (+) Visual
hallucination (+)
Content of Thought
Delusion of Envious,
magic-mystic and
Suspicious, Thought of
Insertion
Form of thought: nonrealistic

Impairment

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
F25.1 Schizoaffective Disorder
Depressif type
F20.5 Skizofrenia Residual

Multiaxial Diagnosis
Axis
Axis
Axis
Axis

I
: F20.0 Paranoid Schizophrenia
II
: Z03.2 No diagnosis
III
: No diagnosis
IV
: Problems with the primary
support group (family)
Axis V
: GAF on admission 21-11

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 2 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