Name : Mr.

S
Age : 32 years old
Gender : Male
Address : Grabag,
Magelang
Occupation : Unemployed
Marriage status : Single
Last education : Junior High
School
Name : Mr. MS
Age : 65 years old
Relation : Father


GUARDIAN PATIENT
Keep kicking the doors house
Easily got angry



STRESSOR

Unclear
Patient was graduated from junior high
school and wanted to continue at Taruna
Nusantara High School but he was failed in
the admission test. Since then, he changed
behaviour :
Easily got angry
Attack people
Destroy things

2005
Since then
he often
admitted to
the RSJS
Magelang (9
times)

- He did not continue studying
- He did not socialize with neighbours
- He poorly utilize his leisure time
- He did not took goodcare of himself



After discharged from hospital, he continued :
Could not sleep
Wandering around in the early morning to buy cigarette.
Often get angry for unknown reason
Saw her sister shadow insulting him and taunt him to
fight


He didnt want to work
Poor utilization of leisure time
He could take care of himself
February 2014
Keep kicking the door
Get angry for unknown reason
Saw shadow taunt and insulting
him
Cannot sleep at appropriate
time
Wandering around in early
morning
Day of admission
Brought to
RSJS ER
by his
father

He didnt want to work
Poor utilization of leisure time
He could take care of himself
The patient was admitted to
the RSJS Magelang for nine
times because of paranoid
schizophrenia
Psychiatric
history
Head injury (-)
Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)
History of admission (-)
General
medical
history

Drugs consumption (-)

Alcohol consumption (-)

Cigarette Smoking (+)
Drugs, alcohol
abuse, and
smoking history
Patients family can not recall any impairment on growth and development. Other
milestone can not be assessed properly.

Psychomotoric (no valid data)
There is no valid data when patient:
first time lifting the head (3-6 months) (rolling over (3-6 months)
Sitting (7-8 months)
Crawling (6-9 months)
Standing (6-9 months)
walking-running (16 months)
holding objects in her hand (3-6 months)
putting everything in her mouth (3-6 months)

Psychosocial (no valid data)
Parents can not recall the times when 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)
They were forgot on when patient started saying words 1 year like mom
or dad. (1 year old)

Emotion (no valid data)
They were forgot of patients reaction when playing, frightened by
strangers, when starting to show jealousy or competitiveness towards
other and toilet training.

Cognitive (no valid data)
They were forgot on which age the patient can follow objects, recognizing
her mother, recognize her family members.
They were forgot on when the patient first copied sounds that were heard,
or understanding simple orders.
Psychomotor (no valid data)
forgot on when patients first time playing hide and seek or if patient ever
involved in any kind of sports.
Psychosocial (no valid data)
forgot about patients social relation.
Communication (no valid data)
forgot regarding patient ability to make friends at school and how many
friends patient have during his school period
Emotional (no valid data)
forgot on patients adaptation under stress, any incidents of bedwetting were
not known.
Cognitive (no valid data)
forgot on patients cognitive.
Sexual development signs & activity (no valid data)
Patient first experience of wet dreaming, etc.
Psychomotor
Patient had hobby (playing football)
Psychosocial
Parents claimed that he had some friends.
Emotional (no valid data)
There is no valid data on patients reaction on playing, scared,
showed jealously or competitiveness
Communication
Patient can communicate well.
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
Patient is the fifth child with four siblings
Psychiatry history in the family (-)
Patient
Patient knows that he is male, his behavior is
appropriate for male, hes attracted to woman.


Psychosexual history
Socio-economic history
Economic scale : average
Validity
Alloanamnesis : valid
Autoanamnesis : not valid
Symptom
Role function
2005 2014
Mental State
(Monday 17th March 2014)
Appearance
A man, appropriate to his age, completely clothed
State of Consciousness
Clear
Speech
Quantity : increased
Quality : decreased
Behaviour
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizzare
Command automatism
Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia
ATTITUDE
Non-
cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excitement
Emotion
Mood
Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed
Affect
Appropriate
Inappropriate
Restrictive
Blunted
Flat
Labile
Disturbance of perception
Hallucination
Auditory (+)
Visual (+)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-) Derealization (-)
Thought progression
Quantity

Logorrhea
Blocking
Remming
Mutism
Talkative
Quality
Coherence
Irrelevant answer
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigrasi
Perseverasi
Sound association
Word salad
Echolalia
Content of thought
Idea of Reference
Idea of Guilt
Preoccupation
Obsession
Phobia
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
Idea of suicide
Form of thought
Realistic
Non Realistic
Dereistic
Autistic

Sensorium and Cognition
Level of education : Good
General knowledge : Good
Orientation of time : Good
Orientations of place : Good
Orientations of peoples : Good
Orientations of situation : Good
Working/short/long memory: Good
Writing and reading skills : Good
Visuospatial : -
Abstract thinking :-
Ability to self care :Good

Impulse control when
examined
Self control: Enough
Patient response to
examiners question:
Good
Insight
Impaired insight
Intellectual Insight
True Insight
Internal Status
Consciousnes : compos mentis
Vital sign :
Blood pressure : 120/80 mmHg
Pulse rate : 98 x/mnt
Temperature : Afebris
RR : 20 x/mnt, regular

Head : normocephali
Eyes : anemic conjungtiva -/-, icteric sclera -/-, pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax:
Cor : S 1,2 Sound and normal
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill <2, tremor (-)
Neurological exam : not examined
Symptoms
Mental Status
Mood: irritable,
inappopriate.
Talk active
Loosening of
association
Auditory and visual
hallucination
Dellusion of magic-
mystic, suspicious, and
grandiose
Impaired insight

Impairment
He didnt want to
work
Poor utilization of
leisure time

Keep kicking the
door
Get angry for
unknown reason
Saw shadow taunt
and insulting him
Cannot sleep at
appropriate time
Wandering around in
early morning


Differential Diagnosis
F20.0 Paranoid Schizophrenia
F25.0 Schizoaffective Manic Type
Multiaxial Diagnosis
Axis I :F20.0 Paranoid Schizophrenia
Axis II : skizotipal
Axis III : -
Axis IV : unclear
Axis V : GAF on admission 30-21

1. Problem about patients family
He was failed to continue his study at high school

2. Problem abour social economy
his economic condition is average

3. Problem about patients biological state
In Schizophrenia there is abnormal balancing of the
neurotransmitter (increasing of dopamine) which has the
contribution for the positive symptoms : destroy thins, have
delusion and hallucination. We need pharmacotherapy for
re-balancing the neurotransmitter
Inpatient (hospitalization)
Purpose of hospitalization is to decrease
the symptoms :
Wandering around,
Destroy things
Response Remission Recovery
Target therapy : 50% decrease of symptom
(wandered around, destroy things, hallucination, delusions)

Emergency department
Antipsychotics : Inj. Haloperidol 5mg i.m.
because the patient has positive symptom
(wandered around, destroy things , hallucination, delusions)

Maintance
Haloperidol 2x5mg per oral

Suggest : ECT
Re-assess patient
Target therapy :
100% remission of symptom within 4-9 months
(wandered around, destroy things, hallucination,
delusions)

Inpatient management
1. Continue the pharmacotherapy: Haloperidol 2x5 mg po
2. Improving the patient quality of life :
teach patient to care about himself (took a bath,
toothbrushing)
Teach patient about his social & environment
( moping, clean the floor, washing the dishes)

Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy

Target therapy : 100% remission of symptom
within 1 year.
(wandered around, hallucination, delusions)
Continue the medication, control
to psychiatric
Rehabilitation : help patient to
got & apply his skill
Family education