CASE REPORT

A man, 29 years old, was admitted to emergency unit of HB Sa’anin Mental

Hospital on Friday December 8th, 2010 by him uncle because of being agitated,
angry with no reason, irritable, push down his mother, throwing stone to the
school, feels that his head was pulled by an angel, that force him to take in
marriage with some one called Epi. These behavior was start since 4 days ago.
This is a his second illness since 8 years ago, and being hospitalized for the
second time.

PATIENT IDENTITY:

Name : Sukran
Age : 29 years old
Place/ date of birth : Padang, July 31st 1981
Marital status : Single
Occupation/ education : Cleaning Service/ Islamic Senior High School
(graduated at 5th grade)
Address : Sungai Rotan, Nagari Batang Taba, Kec. Ampek
Angkek, Kab. Agam, West Sumatera
Religion : Islam
Citizen : Indonesia
Race : Sikumbang

INTERNAL STATUS
General status : compos mentis cooperatif
Blood pressure : 110/70mmHg
Heart rate : reguler, frequency 80/minute
Respiratory rate : abdominal, reguler, frequency 24/minute
Temperature : 370C
Respitatory system : in normal range
Cardiovascular system : in normal range
Digestive system : in normal range

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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 are good

IV. Vegetatif neuron
V. Supreme functions
VI. Specific disorders
: eating normally (3x1 portion/day), sleep normal.
: reading, writing, drawing can be done well
: - stiffness : none
- tremor: none
- nasal stiffness: none
- occulorigic crisis: none
- torticolis: none

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 AUTOANAMNESA at Desember, 20th 2010

Questions Answers Interpretation

- Assalamu’alaikum pak, - Walaikumsalam
- Samo pak sukran kan? - Iyo,
- Perkenalkan ambo Aziz samo - Yo ndak baa do
Akhnal, dokter muda di siko,
ndak baa mangecek sabanta do
kan pak?
- Namo panggilan pak sukran ko - Sukran
apo pak?
- Lai sehat-sehat sajo kini pak? - Lai,
Apo yang taraso kini pak? - Ndak ado doh
- Umua nyo bara kini pak? - 32 tahun
- Tanggal bara apak lahia? - 31 juli 1981
- Kini ko apak tau apak dima? - Lai, di rumah sakik jiwa
- Sajak bilo di siko? - Sajak hari kamis yang dulu
- Lah bara minggu di siko? - Lah duo minggu
- Sia yang manta kamari? - Paman, adiak ama
Discriminative
- Cubo caritokan baa dek bisa - Disuruahnyo pai barubek, eh insight distrub
sampai di siko! beko ditingga nyto wak disiko,
padahal awak ndak ado sakik do,
awak kan sehat pak.
- Dulu pernah lo di siko? - Pernah, disuruah nyo juo pai
barubek.
- Urang tuo lai masih ado juo - Apak lah maningga, amak lai
baru? masih ado juo baru
- Bara urang baradiak kakak? - balimo
- Apak anak ka bara? - anak ka tigo
- Apak sakolah lulus a? - awak sakolah di MTI, sampai
kelas limonyo, ndak lulus do
- Baa kok sampai baranti? - maleh wak sakola lae

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- Ado ndak berang-berang ndak
tantu?
- Baa dek berang?
- Manga nyo malaikat tu?
- Dari ma tau ado malaikat?
- Ado nampak nyo?
- Tabaun yo?
- Baa baunnyo?
- Ma lo bisa urang maliek
malaikat jo mambauni
baunnyo?
- Waktu disuruah kawin samo si
epi tu, lai nio pak sukran?
- Tu ndak malawan ka malaikat
tu?
- Salain malaikat ado ndak yang
mamaso syukron untuk kawin?
- Kalau jalan-jalan surang ndak
tantu arah?
- Tu apo lae kecek malaikat tu?
- ado
- yo, awak di paso kawin samo si Auditoric
epi dek malaikat, disihirnyo hallucination
kapalo awak
- disihirnyo kapalo awak,
keceknyo kawin ang samo si epi.. Olfactoric
- tadanga keceknyo, hallucination
- ndak ado nampak do
- iyo, ado tabaun
- kadang baun minyak kimeri gae,
Discrimination
harum pokoknyo
judgment disturb
- lai bisa awaknyo
- ndak nio awak do
- lai malawan, awak bae gae pintu,
Delusion
kaco gae
- ado, ayah wak, dituduhnyo wak
bazina jo si Epi, padahal ndak
ado doh, tu dipasonyo wak
kawin, Padahal ayah wak ko yang
acok selingkuh mah
- lai, awak dikaja dek malaikat tu,
- disuruahnyo sumbayang,
keceknyo rajin-rajin sumbayang
jo mangaji, beko masuak sarugo,
makonyo kini wak rajin
sumbayang pak, ndak ado lae
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- Kini masih ado ndak malaikat - ndak ado do
tu?
- Pak sukran ado ndak maraso - lai, ayah wak tu mah yang
dikecek-kecekan urang? mangasuang urang-urang.
- Tau apak kini tanggal bara? - 20 Desember 2010
- Hari a kini? - senin
- Dari ma tau? - wak caliak di papan
- Kalau kini senin, besok bararti - selasa
hari a pak?
- Presiden wak kini tau? Sia? - tau, SBY
- A kepanjangannyo? - susilo bambang yudoyono
- Wakil preseiden? - jusuf kala
- Kini lai tau, apak ado di kota - lai, di kota padang
ma?
- Sabalah ma kalau awak dari - sabalah barat
bukittinggi
- Kalaw Jakarta sabalah ma - sabalah selatan
padang tu? - Indonesia
- A Negara wak kini?
- Ibu kotanyo? - Jakarta tu
- Besok kalaw lah sehat ingin - Iyo, awak ingin manyapu liak
karajo a pak? - Iyo pak
- Iyo pak, itu sajo lah nyo pak
yoh, tarimo kasih

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ALLOANAMNESIS :

Name : Zamzami

Age : 27 years old

Address : Sungai Rotan, Nagari Batang Taba, Ampek

Angkek, Agam, West Sumatera

Occupation/ education : Farmer

Relationship with patient : Uncle

1. Main reason of hospitalization

Since 4 days, patient was being agitated, angry with no reason,
irritable, push down his mother, throwing stone to the school, feels that his
head was pulled by some one, that force him to take in marriage with some
one called Epi.
2. Present complain of patient
No complain
3. History of illness:
Beginning from
2003:
Agitation, patient said to his family that he got wahyu from an angel
that command him to shalat and mengaji, patient was not brought by
his family to the hospital because patient was not annoying.
2008 (March):
Hospitalized in HB Saanin Padang for 15 days because patient was
being agitated, angry with no reason, irritable, push down his mother,
throwing stone to the school, feels that his head was pulled by some
one, that force him to take in marriage with some one. After that
patient got regular control in the Puskesmas in his village, but he was
not obedient.
2010 (November): not control in Puskesmas and drop out of medication.
2010 (Desember):
hospitalized because the same cause

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4. Premorbid history
Neonatus : Born spontaneously, no history of cyanosis and jaundice.
Childhood : Growth and development appropriate with age
Adolescence : Growth and development appropriate with age

5. Education history

Elementary school : State Elementary School of Sungai Rotan, Nagari

Batang Taba, Ampek Angkek, Agam, West Sumatera,
pass in 6 years.

Junior and Senior High School : Madrasah Tarbiah Islamiah Canduang,

Ampek angkek, Agam, West Sumatera (didn’t pass, just
till 5th grade, normaly 7 grade)
6. Job History
Cleaning service at State Elementary School of Sungai Rotan, Nagari
Batang Taba, Ampek Angkek, Agam, West Sumatera

7.Marital status: Single

8. Social State Condition:

He uses to live with her father, mother, in semipermanent house, with water
from the well and electricity.
Income: - retiring salary: Rp. 300.000,-
- from his brother : Rp. 150.000,-

Outcome: -daily needs: Rp. 450.000,-

Rest of money: Rp. 0,-
Saving: Rp. 0,-

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9. History of familial Disease
♂ ♀

♂ ♀ ♂
♂ ♀

♂ ♂ ♂ ♂ ♀
patient
There is no other family member that have mental problem

10. Graphic

2003 2008 2010

RESUME AND CONCLUTION OF PSYCHIATRIC EXAMINATION

1. General Status
Consciousness/sensorial : compos mentis/good
Attitude : cooperative
Motoric : active
Facial expression : rich
Verbalization : can speak fluently
Physical contact : could be done
Attention : good
Initiative : good

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2. Specific condition
A. Affective
1. Affective condition : blunt
2. Emotional :
a. Stability : stable
b. Control : stable
c. Echt/unecht : echt
d. Einfulung : adequate
e. Deep/shallow : shallow
f. Differentiation scale : narrow
g. Emotional flow : slow
B. Intellectual condition of function
a. Memory : good
b. Concentration : good
c. Orientation : good
d. Knowledge : appropriate
e. Discriminative insight : disturbed
f. Intelligence prediction : average
g. Discriminative judgment : disturbed

C. Sensation and perception abnormalities

1. Illusion : none
2. Hallucination :
- Acoustic : present since 2 years ago, now
disappeared
- Visual : none
- Olfactory : present since 2 years ago, now
disappeared
- Tactile : present until now
- Gustatoric : none
D. Abnormal of Thought process
1. Thought velocity : slow

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 2. Thought quality :
a. Clear and sharp : clear and sharp
b. Sircumstantiality : none
c. Incoherent : none
d. Stagnant : none
e. Blocking : none
f. Flight of ideas : none
g. Verbigeration : none
h. Perseverative : none
3. Thought condition
a. Central mindset : centrally
b. Phobia : none
c. Obsession : none
d. Delusion : present
e. Suspicion : present
f. Confabulation :. none
g. Repulsion : none
i. Inferior feeling : none
j. Much/little : much
k. Feeling guilty : present
l. Hypochondria : none
m.Others : 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

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 j. Others : none
F. Over anxiety : none
G. Reality testing ability : disturb in behavior,
thinking and feeling

RESUME MULTIPLE AXIS

Axis I. Clinical Syndrome

Agitated, angry with no reason, irritable, push down his mother, throwing stone
to the school, feels that his head was pulled by some one (angle) that force him
to take in marriage with some one.

Physiatric examination:

General appearance : compos mentis/good, cooperative, active, rich, can

speak fluently, could be done, attention and initiative are good.
Specific condition :
a. Affective Condition : blunt, emotional stability and control stable
echt,einfulung inadequate, swallow, differentiation scale narrow,
emotional flow slow.
b. Intelectual condition and function : memory good, consentration
good, orientation good, knowledge appropriate, discriminative
insight disturbed, intelligence prediction average, discriminative
judgment disturbed
c. Sensation and perception abnormalities : no illusion, hallucination
present (auditoric, olfactory, tactile)
d. Thought process condition : slow, clear and sharp,delusion
present,suspicion present, feeling guilty present
e. Instingtual drive and behavior abnormalities : none
f. Over anxiety : none
g. Reality testing ability : disturb in behavior, thinking and feeling

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Axis II : personality disorder and mental retardation disorders

Personality : good relation with family

Mental retardation: none

Axis III : general medical condition

There’s no history of malaria, typhoid, capitis trauma, and other disease that
need to be hospitalized

Axis IV : Psycosocial stressor and environment

Stessor from his economic condition

Axis V :Global Assessment of Function

1. Social: social relation (visit friend) can’t do it since 20 days before

2. Daily activity: sweeping, washing can’t be done

3. Free time activity: watching tv, recreational activities were restricted

MULTIPLE AXIS DIAGNOSIS

I. F20.0 schizophrenia paranoid

II. No diagnosis

III. No diagnosis organic

IV. Stessor from his economic condition

V. GAF 70-61

DIFFERENTIAL DIAGNOSIS

I. F.25.0 schizoaffective manic tipe

II. F. 20.8 other schizophrenia

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THERAPY:

 Haloperidol tab 3 x 2 mg

 Chlorpromazine tab 3x100 mg

PROGNOSIS

Clinis : dubia at bonam

Functional : dubia at bonam

Social : dubia at bonam

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