PSYCHIATRIC PATIENT`S STATUS

A male patient, 26 years old, was admitted to Cendrawasih ward Prof.HB.Saanin Hospital of
Psychiatric on February,27th 2012 at morning. Patient was admitted from emergency room
accompanied by family. This is his six time being hospitalized.

Patient`s Identity :
Name : Ade Julianto
Sex : Male
Date of birth/ age : February, 26th, 1985 (27 years old)
Place of birth : Kasang
Occupation : Ojek`s driver
Education : Senior high school
Marital status : Single
Address : Komp. RSTP Padang, RT/RW 05/07, Kel. Limau Manis Selatan, Pauh,
Padang
Religion : Islam
Civilian : Indonesian
Ethnic : Minangkabau

Internal Status
General appearance : Composmentis
Body space : Astenicus
Blood pressure : 100/70 mmHg
Pulse : 82 x/minute
Breath : 20 x/minute
Temperature : 36,50 C
Respiratory system : No abnormality detected
Gastrointestinal system : No abnormality detected
Neurological status
Cranial Nervous (five senses) : Vision, smelling, hearing, tasting, and tactil are well
Meningeal Signs : neck stiffness (-)
High Intracranial Pressure Signs : progressive headache (-), projectile vomitus (-)
Eyes
- Movement : Free to all direction, nystagmus (-)
- Perception : Diplopia (-)
- Pupil : Round shape and isokor
- Light Reflex : +/+
- Convergence Reaction : Not examined
- Cornea reaction : Not examined
- Ophtalmoscopic examination : Not examined
Motoric
- Tonus : Eutonus
- Turgor : Good
- Strength : Good 555 555
555 555
- Coordination : Good
- Reflex : Physiologic (+/+)
Pathologic (-/-)
Sensibility : Smooth and rough are good
Vegetative Function : Good appetite, sleep well
Basic Function : Reading, writing, drawing, activities and language can be done
well
Specific disorder
- Rigidity : None
- Tremor : None
- Nasal Stiffness : None
- Oculogyric Crisis : None
- Torticolis : None
- Others : None
Laboratory Examination : none

Alloanamnesis:
Taken from :
Name/ age : Indra/ 45 years old
Address : Komp. RSTP Padang, RT/RW 05/07, Limau Manis Selatan,
Pauh, Padang
Occupation : civil servants
Relationship with the patients : uncle

Primary cause of hospitalization

Patient was agitated, threatening the family because he wanted to get married, damage household
appliances, a temper tantrum if her demands were not met, almost never slept, since 2 days ago,
patient had the supposition of being a great man. This is his sixth time of sick and hospitalized.
Now more severe illness than previously.

Present complain of patient

There is no complaint at this time.

History of illness:
2003 (forgot the month)
The patient got angry, rage, and throwing things at home. The patient previously broken up
with his girlfriend. At the time, the patient is being studied at the Andalas University
majoring in Minangkabau literature, eventually the patient dropped out of college. Then, the
patient was taken by family to the Psychiatric Hospital HB Saanin Padang and treated for
about 1 month. Control regularly, take medication regularly.

2004 (forgot the month)

Patient returned angry, agitated, throwing things at her house, threatened his family and feels
that he was the owner of Minangkabau International Airport. Several months before the
patient wasn`t taking medication regularly. The patient treated in RSJ HB Saanin Padang and
for 1 month. Control regularly, take medication regularly.

2005 (forgot the month)

Patient attempted suicide by drinking Baygon, and taken to the hospital by his family. Patient
re-admitted to the Psychiatric Hospital HB Saanin HB for 1 month, control regularly, take
medication regularly

2007 (forgot the month)

Patient agitated, rage, destroy household appliances, breaking glass cabinets, burning stuff
and chicken coop that was near his home. Readmitted to the RSJ HB Saanin, treated for 2
months, control regularly, take medication regularly.

2011 (around January)

The patient got angry, rage, throwing things at home, breaking glass cabinets, threatening the
family, and burning the stuff. Readmitted to the RSJ HB Saanin, treated for 1 months, control
regularly, take medication regularly.
 2012 (February)
Patient was agitated, threatening the family because he wanted to get married, damage
household appliances, a temper tantrum if her demands were not met, almost never slept,
since 2 days ago, patient had the supposition of being a great man.

Premorbid history
Infant : born spontaneously, birth was assisted by midwife, no history of
jaundice, cyanosis, and seizure, history of congenital abnormality
(patient had no anus at birth, got operated)
Childhood : growth and development suitable for his age.
Adolescence : had a lot of friends, easy making new friends and outgoing person

Job History
Patient is An ojek`s driver

Educational background
- Elementary school : - SD 32 Bungo Pasang
- SD 11 Lubuk Buaya
- Junior High School : SMP 15 Padang
- Senior High School : SMA 8 Padang
- University : Studied Minangkabau literature at Andalas University

Social economy history

Patient live with his parents, siblings, and uncle, live in permanent house with electricity and
television, water supply from PDAM, patient had a motorcycle and work as an ojek`s driver. His
father is a security in BIM, and his mother is a teacher in SMP 15 Padang.

Marriage background
None

Family history of illness

Ket : kakek pasien juga menderita gangguan jiwa

Pasien

Graphic of illness

2003 2004 2005 2007 2011 2012

Autoanamnesis

Questions Answer Interpretations

Assalamualaikum pak Waalaikum salam
Perkenalkan kami dokter muda
Buliah bana buk, tanyo-tanyo
psikiatri di siko, namo awak
lah, panyakik ambo ko aneh bin
silvia, namo kawan wak stefilla,
ajaib, ambo sabalumnyo dari
wak nio batanyo, lai buliah pak ?
IGD, 3 hari 3 malam ambo
dikabek, tapi nda` do taraso apo-
apo do
Sia namo apak? Ade Julianto
Dima apak kini ko? Di rumah sakik jiwa HB Saanin
Sadang apo apak disiko? Tu lah buk, ambo dibawok Discriminative insight
kamari, padahal ambo nda` sakik disturbed
do
Dulu pernah apak kasiko? Dulu iyo buk, dulu tu iyo dek
ambo gilo, makonyo keluarga
ambo mambawo` kamari, tapi
kini ko ambo nda` sakik do, alah
5 kali ma ambo disiko
Kini baa kok apak dibawok Giko caritonyo buk, jadi ambo
kamari? ngamuak di rumah, ambo
pacahan barang-barang di rumah,
tapi nda` ado taraso apo-apo do
buk, nda` sabaginyo gai tangan
ko do
Kok bisa gitu pak? Iyo, jadi caritonyo, ambo kan Halusination is present
punyo ayah, namonyo Hasan Delusion is present
Basril, catat yo bukayah ambo
tu kapalo Bandara Minangkabau
tu buk, ibuk ambo guru SMP,
kini lah jadi kapalo sekolah nyo
buk, ayah awak tu punyo ayah lo
nda` buk, nyo gilo tu buk, abis tu
dek gilo tu jadi harimau nyo buk,
Nampak dek awak nyo buk,
harimau tu lah nan masuak ka
badan awak buk, makonyo awak
 jadi kuek buk, awak macah-
macahan barang tu nda` do
taraso apo-apo do buk, awak
urang gadang ma buk
Sia yang maantaan apak kamari? Apak amo mamak wak
Lai tau presiden kini sia pak Lai buk, SBY, dari partai Orientation is good
demokratnyo buk
Lai tau hari apo kini pak ? bulan? Senin ,bulan februari tahun 2012 Orientation is good
tahun?
Tanggal bara kini pak? Tanggal 27 buk Orientation is good
Waktu tu ado apak danga suaro- Ndak ado do buk,
suaro?
Ado mencium bau-bau busuak Ndak ado
/harum?
Ado raso curiga-curiga ka urang? Ndak tau do buk
Ado ndak takuik ka sesuatu? Ndak buk, awak urang gadang Halusination is present
kalau awak lah marokok tu buk, Delution is present
masuak arwah harimau tu ka wak
kan, kuek awak habis tu, bisa
wak mengendalian urang buk,
ambo kiliah dulu ma buk, di
unand jurusan sastra
minangkabau, pintar awak ko ma
buk, urang gilo paling pintar
sedunia
Ado apak maraso badoso kini? Ndak ado
Apo karajo uni? Ambo jadi tukang ojek buk
Ado apak maraso dandam ka ndak
urang kini?
Yo lah pak, makasi banyak yo Yo..samo-samo
pak. Jan lupo minum ubek yo
pak.

SUMMARY OF PSYCHIATRIC EXAMINATION

Examination is on February, 27th 2012
1. General appearance
Consciousness/sensorial : compos mentis/good
Attitude : cooperative
Motoric : active
Facial expression : rich
Verbalization : speak clearly
Physic contact : could be done / appropriate / long period
Attention : good
Initiative : good
2. Specific condition
A. Affective
1. Affective condition : hypertim
2. Emotional :
a. Stability : stable
b. Control : good enough
c. Echt/unecht : echt
d. Einfuhlung : inadequat
e. Deep/shallow : shallow
f. Differentiation scale : narrow
g. Emotional flow : fast
B. Intellectual condition of function
a. Memory : good
b. Concentration : good
c. Orientation : good
d. General and schooling knowledge : can not predicted
e. Discriminative insight : disturbed
f. Intelligence prediction : average
g. Discriminative judgment : disturbed
h. Intelectual deterioration : none
C. Sensation and perception abnormalities
1. Illusion : none
2. Hallucination :
Acoustic : none
Visual : present
Olfactory : none
Tactile : none
Gustatory : none

D. Thought process condition

1. Speed of thought processs : fast
2. Quality of thought process:
a. Clear and sharp : clear and sharp enough
b. Circumstantial : none
c. Incoherent : none
d. Sperrung : none
e. Hemmung : none
f. Flight of ideas : none
g. Verbigeration : none
h. Preservation : none
3. Thought condition
a. Central pattern : none
b. Phobia : none
c. Obsession : none
d. Delusion : present
 e. Suspicion : none
f. Confabulation : none
g. Repulsion : none
h. Inferior feeling : none
i. Much/little : much
j. Feeling guilty : none
k. Hypochondria : none
l. Others : none

E. Instinctual drive and behavior abnormalities

a. Abulia : none
b. Stupor : none
c. Raptus/impulsivity : none
d. Excitement state : present, since 5 days ago
e. Sexual deviation : none
f. Echopraxia : none
g. Vagabondage : none
h. Pyromania : none
i. Mannerism : none
j. Others : none
F. Over anxiety : none
G. Reality testing ability : disturb in behavior, feeling and thinking

MULTIPLE AXIS RESUME

Axis I. Clinical Syndrome
Patient was agitated, threatening the family because he wanted to get married, damage
household appliances, a temper tantrum if her demands were not met, almost never slept,
since 2 days ago, patient had the supposition of being a great man. This is his sixth time
of sick and hospitalized. Now more severe illness than previously.

General Appeareance: compos mentis, cooperative, active, rich, can speak clearly, psychic
contact could be done, appropriate and long enough.

Specific condition:
a. Affective condition: hypertim, stable, good enough, echt, inadequate, shallow, narrow,
fast.
 b. Intellectual condition and function: good memory, concentration is good enough, good
orientation, absent intelectual deterioration, discriminative insight and judgment are
disturbed.
c. Sensation and perception abnormalities: no illusion, visual hallucination present
d. Thought process condition: fast, clear and sharp enough, delusion present, much.
e. Instinctual drive and behavior abnormalities: excitement state is present, since 5 days ago
f. Overt anxiety: none
g. Reality testing ability, disturbed: behavior, feeling and thinking.
Axis II : Personality Disorder and Mental Retardation Disorders
Personality disorder : none
Mental retardation: none
Axis III : General Medical Condition
History of congenital abnormalities of the anus
No history of traumatic capitis, malaria, typhoid, or other diseases which need
hospitalization
Axis IV : Phsychosocial Stressor and Environment
- Financial
- Patient want to have a pair and get married
Axis V: Global Assessment of Function
Social relationship couldnt be done since
Daily activity culdn`t be done since
Spending time with watching TV, travelling, couldnt be done since

MULTIPLE AXIS DIAGNOSIS

I. F.31.2 Bipolar Affective Disorder Manic Episode with Psychotic Symptoms
II. No Diagnosis.
III. No diagnosis.
IV. Financial
V. GAF 41-50.

DIFFERENTIAL DIAGNOSIS
I. F 31.6 Bipolar Affective Disorder Mixed Episode
 II. F 25.0 Manic type schizoaffective

THERAPY
Haloperidol 3 x 1,5 mg
2. CPZ 1 x 100 mg
3. Karbamazepin 2 x 100 mg

PROGNOSIS
Clinical : dubia at malam
Functional : dubia at malam
Social : dubia at malam