A 21 years old boy was admitted to RSJ HB Saanin emergency unit on Mei 27 th, 2013 at

8.30pm escorted by his family. This patient was permitted to hospitalize by doctor on duty. This is
the third attack and getting hospitalized first time.
Patient Identity :

Name and Age

Age
Place and date of birth
Date of birth
Address and Phone number
Occupation and School
Religion
Citizen
Tribe

A. Internal Status
General appearance
Blood pressure
Pulse rate
Temperature
Cardiovascular system
Digestive system
Specific disorder

: Ade Saputra
: 21 years
: Pariaman
: 10 April 1993
: Lansek Kado, Rauh, Pasaman
: not working / senior high school
: Islam
: Indonesia
: Minangkabau

: Compos Mentis
: 120/80 mmHg
: 84 x per minute
: 36,80C
: No disorder found
: No disorder found
: No disorder found

B. Neurological Status
I. Central nervous system :
Symptoms of brain meningen stimulation: Tremor (-) Rigidity (-) Seizure (-)
Symptoms of intracranial tension: progressive vomiting (-), progressive headache (+).
Eyes : - movement : can be moved to all direction, no nistagmus
- perception: no diplopia
- pupil: round, isokor
- light reaction: no examination done
- convergence reaction: no examination done
- cornea reaction: no examination done
- ophtalmoscope examination: not done
II. Motoric: -tonus: eutonus
- turgor: good
- strength:
555 555
555 555
- coordination: good
- reflex: physiologic(patella): +/+
Pathologic(Babinsky):-/III. Sensibility: smooth and rough: good
IV. Vegetatif neuron: eating normally (3x 1 portion/day), sleep normal.

V. Supreme functions: reading, writing, drawing can be done well

VI. Specific disorders:
- stiffness : none
- tremor: none
- nasal stiffness: none
- occulorigic crisis: none
- torticolis: none

Alloanamnesa :
Alloanamnesis given by :

Name and Age

Address and Phone number
Occupation and higher education
Relationship with patient

: Lamzuardi / 63 Tahun
: Lansek Kado, Rauh, Pasamn
: farmer
: Father

1. Main reason hospitalization

Angry with no reason, agitated, breaking household things, unstable emotion, started to walk
alone ( some times wont come back ). Less sleep ( 4 hours/day ), less eating ( 2 x portion ).
Present complain of patient: dont have
2. History of illness:
2010 ( Month : unknown )
Getting angry without reason. Emotions unstable. Started to talk to himself. Patient is the
second child of the family. Frequently brought to DUKUN. He will be fine for a while after
that than the problem re-occur.
2012 ( Month : Mei )
Angry with no reason, breaking household things, unstable emotion, started to walk alone
( some times wont come back ). Less sleep ( 4 hours/day ), less eating ( 2 x portion ).
Brought to RSJ HB Saanin. He is agitated about a week before admitted to hospital.
3. Premorbid history
Infant
: born spontaneously, birth was assisted by midwife, no history of jaundice,
Childhood
Teenage

:
:

Adult

cyanosis, and seizure.

Growth and development suitable for children his age.
he can associate with any one, can have proper communication, sporting,
respects parent.
Started to isolize himself. Anti-social and easily getting angry.

Educational background
Country Elementary School in Pasaman, completed during 6 year, rangking above 5.
Country Junior High School in Pasaman, completed during 3 year, rangking 02 above.

discontinue to country senior high school because fail in final exam.

4. Social economy Background
live in her house with his parent, permanent semi house, with electricity and get fresh water
from well, with TV. Income around Rp 1,200,000/month and outcome around Rp 1,000,000.
The balance around Rp200,000 but family feel insufient money

5. Family history of illness

Non of the family members had the same problem.

6. Graphic of illness

4
2010

2011

2012

5
2013

AUTO ANAMNESA ( 10 June 2013 )

Questions
Baa kaba kini adi?lai sanang

answer
Lai

Lai lamak lalok tadi malam?

Agak kurang pak

Lai namuah makan?

Lai

Tahun bara kini?

2013

Bulan apo kini?

Bulan 5

Lai tau tanggal bara kini?

Ndak tau

Dima Pak Am kini ko?

Rumah sakik pak

Baa adi kok di baok kasiko?

sakik

Ado mancaliak bayang-bayang dak?

ado

Lai ado mandanga suaro-suaro?

ado

Lai ado raso dipacik-pacik adi?

Ndak

Ado tacium baun-baun?

Dak ado

Ado rasonyo ibo-ibo hati adi?

ado

Maraso jadi urang gadang adi?

Ndak, Cuma orang-orang ketek se di

awak

Ado raso curiga se ka urang?

Dak ado

Raso dikaja-kaja urang?

ado

Ado perasaan badoso ndak?

ado

Ado maraso minder adi ndak?

ndak

Ado raso minder ke orang lain?

ndak

Menurut adi wajar ndak dirawat disiko?

wajar, awak pengen sembuh

Yolah adi..
Mokasih banyak yo

Iyo pak

Summary Of phsyciatric examination

1. General appereance
Counciousness/sensorial
Attitude
Motoric
Facial expression
Verbalization
Physic contact
Attention
Initiative

:
:
:
:
:
:
:
:

compos mentis/good
cooperative
active
rich
good
could be done/inappropriate/long enough
good
present

2. Specific condition
A. Affective
1. Affective condition
2. Emotional :
a. Stability
b. Control
c. Echt/unecht
d. Einfulung
e. Deep/shallow
f. Differentiation scale
g. Emotional flow
B. Intellectual condition of function
a. Memory
b. Concentration

inappropriate

:
:
:
:
:
:
:

stable
normal
echt
adequat
deep
narrow
fast

:
:

low
low

c.
d.
e.
f.
g.

Orientation
Knowledge
Discriminative insight
Intelligence prediction
Discriminative judgment

:
:
:
:
:

C. Sensation and perception abnormalities

1. Illusion
:
2. Hallucination
:
Acoustic
:
Visual
:
Olfactoric
:
Tactil
:
Gustatoric
:
D. Thought process condition
1. Speed of thought processs
2. Quality of thought process:
a. Clear and sharp
b. Incoherent
c. Sperrung
d. Hemmung
e. Flight of ideas
f. Verbigeration
g. Preservation
3. Thought condition
a. Central pattern
b. Phobia
c. Obsession
d. Delusion
e. Suspicion
f. Confabulation
g. Repulsion
h. Inferior feeling
i. Much/little
j. Feeling guilty
k. Hypochondria
l. Others

disturbed( time, place, personal, situation )

can not predict
disturbed
average
disturbed
none
present,
none
none
none
none

fast and unclear

:
:
:
:
:
:
:

unclear and unsharp

present
none
none
present
none
none

:
:
:
:
:
:
:
:
:
:
:
:

none
none
none
present (hearing voice of GOD)
present
none
none
present
much
present
none
none

E. Instingtual drive and behavior abnormalities

a. Abulia
:
none
b. Stupor
:
none
c. Raptus/impulsivity
:
none
d. Excitement state
:
none
e. Sexual deviation
:
none
f. Echopraxia
:
none
g. Vagabondage
:
none
h. Pyromani
:
none
i. Mannerism
:
none
j. Others
:
none

F. Over anxiety

present, abit

G. Reality testing ability

disturb in behavior, feeling and thinking

RESUME MULTIPLE AXIS

Axis I. clinic syndrome
Angry with no reason, agitated, breaking household things, unstable emotion, started to
walk alone ( some times wont come back ). Sick for the third time, hospitalized for the first
time, now is worst than past.
Physiatric examination:
General appereance : compos mentis, cooperative, active, rich, can speak fluently and clear,
psychic contact inappropriate and long enough.
Specific condition:
a. Affective condition : inappropriate, stable,less, echt, adequate, shallow, narrow, fast.
b. Intellectual condition and function: good memory, good concentration, good
orientation; time, Situation, place, personal, knowledge cant predict, discriminative
insight and judgment are disturbed.
c. Sensation and perception abnormalities: none illusion / acoustic present,
d. Thought process condition: fast, unclear and sharp enough
e. Instinctual drive and behavior abnormalities: excitement state none,
f. Overt anxiety: present, abit.
g. Reality testing ability, disturbed; behavior, feeling and thinking
h.

Axis II : personality disorder and mental retardation disorders

Personality: none of friend
Mental retardation: none

Axis III : general medical condition

Theres no history of malaria, typhoid, capitis trauma, and other desease that need to be
hospitalized
Axis IV : physcosocial stressor dan environment
None
Axis V : Global Assesment of Function
Multiple axis diagnosis
I.

F.25.2 Schizoaffective mixed type

II.

No diagnosis

III.

No organic diagnosis

IV.

None

V.

GAF 51-60

Diferensial diagnosis
I.

F20.0 Schizophrenia Paranoid

II.

F 20.3 Undifferentiated Schizophrenia

III.

F.20.6 Schizophrenia simplex

Therapy

Lodomer amp 5 mg

Diazepam amp 10 mg

Haloperidol 3 x 2,5 mg

Chlorpromazine 1 x 100 mg

Prognosis

Clinis

dubia at malam

Functional

dubia at bonam

Social

dubia at bonam

Suggestion for therapy

Psikoterapi

Education to the family