Saturday, 22

th
March 2014

SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ

Identity
Name : Mr. UY
Age : 28 years old
Gender : Male
Address : Petanahan,
Kebumen
Occupation : -
Marriage status : Divorced
Last education : JHS
Name : Mr. B
Age : 46 years old
Relation : Elder Brother
GUARDIAN PATIENT
Talking-singing-shouting non stop too
much




The reason patient was brought to
the hospital
STRESSOR
?
?
?
PAST HISTORY
The first time admitted to RSJS
was because of being violent,
getting angry, and destroying
things. He was then diagnosed
F20.3. he was admitted to RSJS
for about only 1 week, and he ran
away from RS.
2013
- Can work again but very rarely
- He utilized his leisure time hanging out
with his friend, and they give him alcohol
and drugs again
- He took goodcare of himself about so-so
2 months before he was brought, the patient admitted again to
RSJS for the very same reason. After 1 month treated, he ran
away again from RSJS.
2 weeks before he was brought, he started talking-singing-
shouting non stop so the others was feeling disturbed. He also
couldnt sleep and often wandered around randomly.
He cant do his usual work
Poor utilization of leisure time hanging out
with friends, drinking and taking drugs
He could take care of himself
March 2014
PRESENT HISTORY
Patient kept talking-shouting-
singing non stop and uttering
random words.
And he was then brought to
RSJS Magelang
Day of admission
Brought to
RSJS ER
by his
elder
brother
The patient was admitted to the
RSJS Magelang for TWO times
(2013, and January 2014)
because of undifferentiated
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)
EARLY CHILDHOOD PHASE (0-3 YEARS OLD)
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.
INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)
Sexual development signs & activity (no valid data)
Patient firsts wet dreaming, etc.
Psychomotor (no valid data)
There is no valid data on patients hobbies
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.
LATE CHILDHOOD & TEENAGE PHASE
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
Eriksons stages of psychosocial
development
Family history
Patient is the last child with four siblinga
Psychiatry history in the family (-)
Genogram
Patient
Psychiatric Disorder
Patient knows that he is male, his behavior is appropriate for
female, he is attracted to woman.
He has been married for ?? years and has 2 children


Psychosexual history
Socio-economic history

Economic scale : average
Validity

Alloanamnesis : valid
Autoanamnesis : valid
Progression of disorder
Symptom
Role function
2004
2014
Mental State
(Thursday 20th 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
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 : Cant be assessed
General knowledge : Cant be assessed
Orientation of time : Good
Orientations of place : Cant be assessed
Orientations of peoples : Good
Orientations of situation : Cant be assessed
Working/short/long memory : Cant be assessed
Writing and reading skills : Cant be assessed
Visuospatial : Cant be assessed
Abstract thinking : Cant be assessed
Ability to self care : Good

Impulse control when
examined
Self control: Enough
Insight
Impaired insight
Intellectual Insight
True Insight
Internal Status
Consciousnes : compos mentis
Vital sign :
Blood pressure : 130/80 mmHg
Pulse rate : 120 x/mnt
Temperature : Afebris
RR : 24 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
Talking-shouting-
singing randomly
non-stop
Wandering
aroung randomly
Mental Status
Behavior : not cooperative
Affect: inappropriate,
labile
Mood: euphoric
Orientation: difficult to
assess
Form of thought: autistic,
non realistic
Progression of thought:
logorrhea, word salad,
neologisme, sound
association
Insight: impaired
Impairment
Disturbance of
role function
Differential Diagnosis
F20.3 Undifferentiated Schizophrenia
F25.0 Schizoaffective Manic Type
Multiaxial Diagnosis
Axis I : F31.4 Bipolar Disorder with Depressive
Episode and Psycotic Signs
Axis II : no diagnosis
Axis III : no diagnosis
Axis IV :
Axis V : GAF on admission

1. Problem about patients family


2. Problem about social economy
his economic condition is average

3. Problem about patients biological state
In Schizoaffective patient, there is abnormal balancing of the
neurotransmitter (increasing of dopamine) which has the
contribution for the positive symptoms : have hallucination.
We need pharmacotherapy for re-balancing the
neurotransmitter
Problem related to the patient
Inpatient (hospitalization)

Purpose of hospitalization is to decrease the
symptoms :
talking non stop
Wandering around
PLANNING MANAGEMENT
Response Remission Recovery
Target therapy : 50% decrease of symptom
(wandered around, hallucination)

Emergency department
Antipsychotics : Inj. Haloperidol 5mg i.m., Inj. Diazepam
10mg im. (wandered around, hallucination)

Maintenance
Quetiapine 1x200 mg (morning)
Clozapine 1x50 mg (night)

Suggest :
Re-assess patient
Supportive therapy from family
RESPONSE PHASE
Target therapy :
100% remission of symptom within 4-9 months
(wandered around, hallucination)

Inpatient management
1. Continue the pharmacotherapy: Quetiapine 1x200 mg
and Clozapin 1x50 mg po
2. Improving the patient quality of life :
Teach patient about his social & environment
(take care of children, moping, clean the floor,
washing the dishes, etc)

Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy

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