MORNING REPORTSaturday, March 21st , 2015

Supervisor:Dr. Sabar Siregar, Sp. KJ

I

PATIENTS IDENTITYName : Mr. RWAge : 38 years oldSex : MaleAddress : Secang AtasJob : LaborMarital status : MarriedEthnicity : JavaneseEducational status : Junior High School

GUARDIAN IDENTITYALLOANAMNESIS WAS CONDUCTED TO : Name : Mr. CAge : 45 years oldSex : MaleAddress : Secang AtasJob : SecurityEducation: Senior High SchoolMarital status : MarriedEthnicity : JavaneseRelation: Brother in Law

REASON COME TO HOSPITAL Patient come and was accompanied by his family because he feel threatened.

STRESSORhis father died 1 month agobroken heart and bullied by his girlfriend and his friend when he was STM student (21 years ago)

PROGRESSION OF ILLNESS(ALLOANAMNESIS AND AUTOANAMNESIS)

1995patient's heart was broken, patient was bullied by his girlfriend and his friends when he was STM student.patient was angry and rampage with no reason.patient said that he heard girl voices which told to kill him self and comment about his appearance. The voices was heard on his ears, repeatly, when he was aware, alone, only he could heard that. patient stopped to school and started to work.patient was hospitalized in RSJ Semarang for 40 days

1995-1998because his condition, his mother was brought to "Dukun". "Dukun" who told that the patient had to married if want to healthly.patient was mated by his mother.patient got married for 3 months. his wife left him when his wife was pregnancy (2 months). he thought that his wife didn't love him because after that his wife got married with another man.

...CONTINUEDpatient conditions was deteriorated. he started to angry and rampage with no reason.patient also threatened another people but didn't injured anyone.His quality of doing his activity was decreased. Sometimes he forgot to do some of the work.Patient started to lose appetite. He only ate a half plate of his food and sometimes refused to eat.

1999-2000patient still heard that voices.patient also smell stink such as carcass although there wasn't carcass. he smell it repeatly, when he was aware, alone, and only him who could smell it by his nose. patient often angry with no reason. he also threatened his neighbours with no reason.patient isolated himself in his house.patient didn't want to went to work again but still do his hobby such as played keyboard and guitar.His family concern about his behavior, so they took him to RSJ Semarang again for 1 month.

2001-2008for a long procedures, finaly patient was legal divorce with his wife.patient also still got angry and rampage with no reason.patient started to saw the shadows which followed him everytime when he was aware, alone and only he could see it. he felt so scare and felt threatened.because of that, patient take a medicines poorly (drug abuse). patient thought that was reduced his hallucination which made him threatened.patient still do his work but felt lazy than before.

2009-2011patient told that something move in his skin but there was nothing on his skin. he thought sure he was "santet" by the shawdows.patient got more scared. he isolated himself.patient didn't want to eat and take a bath. he also didn't work.due this conditions, his family brought hime to RSJ Semarang and hospitalization for 1 months.

2012-2014Because patient felt better, he checkup regularly but taking his medication poorly (drug abuse).no one care whether he took the medication or not.patient conditions still same (angry, rampage with no reason, heard voices without sources, saw shadow, smell stink and felt something move on his skin) but patient take a bath and ate without command and started go to work as labor again.

FEBRUARY 2015patient's father died on february 17th 2015.it makes patient's conditions become bad anymore.patient told that his halucinations was more stronger and made him more threatened.patient also said that when he watched news tv, the reporter talking about him.

....CONTINUED...patient isolated himself in his house. he didn't want to meet anyone expect his music friends.patient didn't eat, work and difficult started to sleepPatient started to had a little trouble in communication, and not doing his duty at home.

MARCH, 21ST 2015 (DAY OF ADMISSION)patient ask his brother in law to companied him to RSJSMpatient said that there was someone who want to kill him, pursed him since 1 week ago and he sure about that.patient still also sure when he watched news tv, the reporter talking about him.patient believe that there was neighbours want to kill him.patient suspicious to his older brother. he believe that his older brother hated him and want something bad happend to him.patient thought sure that his mind was sucked by the shadow and his mind was empty.

patient conditions still same (heard voices without sources, saw shadow, smell stink and felt something move on his skin)patient was taking his medication poorly (drug abuse).He still communicate well with people but sometimes he tend not to talk.He started to had disturbed sleep again. This time he was hard to get sleep.

...continued... (day of admission)

patient didn't eat for 2 days. he just drunk water. he didn't felt hungry.patient ask his brother in law to companied him to RSJSM because he felt scared and threatened. he hope the hallucination disappeared when he was hospitalization

...continued... (day of admission)

HISTORY OF PAST ILLNESSPsychiatric illness patient was hospitalization in RSJ Semarang in 1995 (40 days), 2000 (1 month) and 2011 (1 month). patient check up in psychiatric clinic regularly but take a medicines poorly. patient consumsed 3 drugs (HPD,THP,RPD)

General medical illnessThere is no history of high fever, seizure, or any other serious illness which needs hospitalization.

Substance abuseThere is a history of alcohol and the othe of NAPZA. but patient is a smoker since in Junior High School. he smokes 1-2 pack for a day.

PROGRESSION OF ILLNESSSymptomsRole Function19952015199820002011

FAMILY HISTORYThere is no history of psychiatric illness in his familyThere is no history of high fever, seizure, head trauma, or any other serious illness which needs hospitalization.

GENOGRAM16 yo

HISTORY OF PERSONAL LIFEPrenatal and perinatalPatients mother was 37 years old during pregnancy and labor, and had no illnessPatient was delivered by normal labor, and by traditional birth attendantsPatient consumed breast milk up to 3 yearsNo valid data about history of Patient's immunization

HISTORY OF PERSONAL LIFEEarly childhood phase (0-3 years old)PsychomotorThere was no valid data in patients psychomotor aspect (such as tilting the body, supine to prone, sitting, standing, walking, smiling, holding her own hand, scoop up object, holding pencil and pilling up two objects)

PsychosocialThere was no valid data in patients psychosocial aspect (such as replying to smile, smiling when seeing interesting object, playing cilukba, knowing her family members and pointing what she wanted without crying)

CommunicationThere was no valid data in patients communication aspect (such as bubbling, cooing, making sounds without meaning, telling 2-3 syllables without meaning and calling mama/papa)

EmotionThere no valid data in patients emotion aspect (such as when patient playing, frightened by strangers, starting to show jealousy or competitiveness towards other, and toilet training)Patient didnt pee or defecate in his pants when he was two years old

CognitiveThere was no valid data in patients cognitive aspect (such as copying sounds that she heard for the first time and understanding simple orders)

History of Personal Life

HISTORY OF PERSONAL LIFEIntermediate childhood phase (3-11 years old)PsychomotorThere is no valid data on patients psychomotor data (such as the first time playing hide and seek or if patient ever involved in any kind of sports.PsychosocialThere was no valid data in patients psychosocial data (such as developing initiative capacity, seeking for socialization, starting social interaction with others, developing self worth in owns abilities and competitive capacity).

CommunicationThere is no valid data on patients communication data (ability to communicate with same age friends/peers, and express needs and wants)EmotionThere is no valid data on patients emotion data (such as ability to experience physiologic response due to emotion)CognitiveThere is no valid data in patients cognitive data (such as knowlegde, understanding , application of knowledge, anylisis, and evaluation abilities)History of Personal Life

HISTORY OF PERSONAL LIFELate childhood and teenage phase (11-18 years old)Psychomotorpatient hobby is playing guitar and keyboard. he had a music group (5 personal). he played it with his group music until now. patient didn't played any sport.PsychosocialPatient started to smoke. he only had 5 friends who played music with him. patient. he rarely go with his friends. he just stayed in his house. or sometimes go to field with his brother in law.CommunicationPatient was taciturn people. he rarely to communication with another people.

HISTORY OF PERSONAL LIFELate childhood and teenage phase (11-18 years old)Emotionpatiient rarely angry. if he didn't like something, he only been quiThere is no valid data in patients emotion data (ability to control physiologic response due to emotion; such as palpitation, increased sweating when angry)Cognitivepatient is a smart student. he always got first rank in class. After graduating from Junior High School, patient continue to Machine High School but didn't graduate because he always was bullied by his girlfriend and his friends. so he stopped to school. patient had moved to the other school ( twice) but he only stayed put for 1 up to 2 months.

HISTORY OF PERSONAL LIFEAdulthood phase (18 years old-now)Educationalpatient didn't continue his study.OccupationalUnemployeeMarital statusPatient is not yet marriedCriminalhe has no criminal historyCurrent situationPatient live with his family.

ERIKSONS STAGES OF PSYCHOSOCIAL DEVELOPMENT

EXAMINATION

PHYSICAL EXAMINATION

GENERAL PHYSICAL EXAMINATIONGeneral appearance: well groomed, well nourishedVital sign: BP: 110/80 mmHgHR:90x/mto: afebrisRR: 20x/m

GENERAL PHYSICAL EXAMINATIONHead : normocephali, mouth deviation (-)anemic conjungtiva (-), icteric sclera (-), pupil isocoreNeck : normal, no rigidity, no palpable lymph nodesThorax:Cor : S1 S2 regular, murmur -, gallop Lung : vesicular sound +/+, wheezing -/-, ronchi-/-Abdomen : flat, abdominal wall//chest wall, normal peristaltic, tympany sound, tenderness -, mass -, liver, spleen and kidney not papableExtremity : Warm acral, capp refill

NEUROLOGICAL EXAMINATIONLevel of Consciousness : compos mentis, E4V5M6 (15)General Appearance :Body posture : normalAbnormal movement : -Walking style : normal

NEUROLOGICAL EXAMINATIONCranial nerves examination:CN I: in normal findingCN II: in normal findingCN III,IV,VI: in normal findingCN V: in normal findingCN VII: in normal findingCN VIII: in normal findingCN IX: in normal findingCN X: in normal findingCN XI: in normal findingCN XII: in normal finding

NEUROLOGICAL EXAMINATIONMotoricUpper extremities: tonus (+), trophy : eutrophic, power of movement : shoulder joint : 5, elbow joint : 5, wrist joint : 5, radial nerve function : 5, ulnar nerve function : 5, median nerve function : 5Lower extremities: tonus (+), trophy : eutrophic, power of movement : hip joint : 5, knee joint : 5, ankle joint : 5

SensoriumDCML system : proprioception, fine touch : no abnormalitiesAL system : vibration, temperature, crude touch, pain : no abnormalities

NEUROLOGICAL EXAMINATIONPhysiological reflexUpper extremities: biceps reflex (+), triceps reflex (+), brachioradial (+)Lower extremities: patella reflex (+), achilles tendon reflex (+)Pathological reflexUpper extremities: Hoffman (-), Tromner (-)Lower extremities: babinski (-), chaddok (-),gordon (-),oppenheim (-), rossolimo (-), clonus -/-Meningeal signNeck stiffness (-), brudzinski neck sign (-), brudzinski contralateral leg sign (-), kernig sign (-)Cerebellum functionAdhyadokokinesia (-), romberg test (-), finger to nose test (no abnormalities), tip to toe walk (no abnormalities)

MENTAL STATE EXAMINATION

GENERAL APPEARANCEA man, age 38 years old, appropriate to his age, calm, and wearing clothes, well groomed and well nourished

ORIENTATIONTime: goodPeople: goodPlace: goodSituation: goodConsciousnessunClear

BEHAVIOR

ATTITUDE

EMOTION

DISTURBANCE IN PERCEPTION

PROGRESSION OF THOUGHT

CONTENT OF THOUGHTIdea of ReferencePreoccupationObsessionPhobia FantasyDelusion of PersecutionDelusion of ReferenceDelusion of EnviousDelusion of HypochondriacDelusion of Magic-mysticIdea of suicidalDelusion of GrandioseDelusion of ControlDelusion of ReligionDelusion of InfluenceDelusion of PassivityDelusion of SuspicionIdea of SuspicionThought of EchoThought of Insertion Thought of withdrawalThought of Broadcasting

FORM OF THOUGHTNon realistic

COGNITIVE FUNCTIONLevel of education: graduated from Junior High SchoolGeneral knowledge: goodWorking/short/long memory: goodWriting and reading skills: goodVisuospatial: goodAbstract thinking: goodAbility to self care: good

IMPULSE CONTROL WHEN EXAMINEDSelf control: EnoughPatient response to examiners question: goodINSIGHTTrue InsightIntellectual InsightImpaired Insight

RESUME

A man, 38 years old, married, labor, felt threatened and be suspicious to everyone more spesific to older brother

SymptomS: Mental Status:Impairment:patient said that there was someone who want to kill him, pursed him since 1 week ago and he sure about that.patient still also sure when he watched news tv, the reporter talking about him.patient believe that there was neighbours want to kill him.patient suspicious to his older brother. he believe that his older brother hated him and want something bad happend to him.attitude : tensionmood : dysphoricaffect : inappropriate, bluntedperception auditory, visual, olfactory, tactile hallucinationthought of procces talkactive, coherentthought of content delusion of control, suspicious, thought of broadcasting, withdrawalthought of form nonrealisticinsight : TRUE insightPatient less socialize with othersPatient does not workhe was hard to get sleep.

Symptoms: Mental Status: Impairment:

patient thought sure that his mind was sucked by the shadow and his mind was empty.patient said that there was someone who want to kill him, pursed him since 1 week ago and he sure about that.patient still also sure when he watched news tv, the reporter talking about him.patient believe that there was neighbours want to kill him.patient suspicious to his older brother. he believe that his older brother hated him and want something bad happend to him.patient conditions still same (heard voices without sources, saw shadow, smell stink and felt something move on his skin)patient was taking his medication poorly (drug abuse).He still communicate well with people but sometimes he tend not to talk.He started to had disturbed sleep again. This time he was hard to get sleep.Patient less socialize with othersPatient does not workhe was hard to get sleep.

DIAGNOSIS

SYNDROME

auditory hallucination that ordered him to kill him self and threatened himvisual hallucination, see shadow that want to kill himolfactory hallucination, smell carcass thingtactile hallucinationthought of withdrawalthought of broadcastdelusion of controldelusion of suspicious

Paranoid Schizophreniasyndrome

DIFFERENTIAL DIAGNOSISF20.0 Paranoid SchizophreniaF25.1 Schizoaffective depressive type

MULTIAXIAL DIAGNOSISAxis I: F20.0 Paranoid Schizophrenia Z91.1 "Ketidakpatuhan minum obat"Axis II: R46.8 Delayed diagnosisAxis III: No diagnosisAxis IV: Stressor : unclear (father died 1 month ago, bullied by his girlfriend and his friends, left by his wife)Axis V: GAF admission 30-21

PATIENTS PROBLEMSBiological problemPositive symptoms because of an imbalance in dopamine activity in the post synaptic neuronPsychological problems being left by his wife, he want to get married again but no one wants to marry him Social problemhe cant socialize well with others

MANAGEMENT

PLANNING MANAGEMENT

PLANNING MANAGEMENThospitalizationpharmacotherapyECTpyschotheraphy

MANAGEMENT PLANNING

HospitalizationPatient was hospitalized because he felt threatened, isolated himself, poor of social, didn't eat and lake to sleep.

Emergency Department Inj. Haloperidol 5 mg 1 Amp IM Inj. Diazepam (sedative and muscle relaxant) 5 mg 1 Amp IV

RESPONSE PHASETarget Therapy50% decrease of symptoms

Maintenance TherapyHaloperidol tab 5mg 2x1

REMISSION PHASETarget therapy : 100% remission of symptom Inpatient managementHaloperidol tab 5mg 2x1Improving the patient quality of life : Teach patient about social & environment (interact with his family, socialize with neighbor or friends, find a hobby to do on his spare time)Outpatient managementContinuation of pharmacotherapyPsychosocial therapy

RECOVERY PHASEContinue the medication, control to psychiatristRehabilitation : Consult to psychologist to help patient finding a hobbyHelp patient to interact normally with his family and neighbour

FAMILY EDUCATIONMental disorders can be controlled by medicines, so it is important to take the medicines routinelyTreat patient like you treat any other peopleHelp patient if he should be helpedDont push patient to understand the family, but her family that has to understand himDont be too emotional to patient

THANK YOU

Yang positif aja dan ndukung ke dx.*Haloperidol 5mg IM kalo gejala positif menonjolRPD kalo gejala negatifECT gaduh gelisah, mutisme*