Case Presentation A 23 years old man was admitted to HB Saanin Padang emergency unit on June 26th 2013, and

escorted by his family. This patient was admitted with nude while running around his home, bother other people, rolling on the heap of rice, always playing toys with a child, feel like a God, talked a lot but incoherent, smiling and laughing alone, restlessness, almost never slept at night, angry for no reason, since two days before hospitalized . Sick for the second time and hospitalized for the first time. The sickness is worse than before. Patient identity: Name and Age MR Gender Place and date of birth Marital status Address Occupation/School Religion Citizen Tribe A. Internal Status General appearance Blood pressure Pulse Respiration Temperature Body Shape Height : Compos Mentis : 110/80 mmHg : easily palpable, regular, 81x per minute, : abdominotorakal pattern, regular, 21x per minute : 36,90C : astenikus : 170 cm
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: : : : : : : : : :

Herzi Razab Putra / 23 years old not identified Male Simpang Empat, February 11th 1990 Single Plasma Tiga Klp 54 Jorong Bukit Nilam Aur Kuning, Pasaman No Occupation/Senior High School Islam Indonesian Mandailing

Barat

Weight

: 68 kg

Cardiovascular system : No abnormality detected Digestive system Specific disorder : No abnormality detected : No abnormality detected

B. Neurological Status Cranial Nervous (five senses) Meningeal Signs : Vision, smelling, hearing, tasting, and tactil are well : None

High Intracranial Pressure Signs : None Eyes Movement Perception Pupil Light Reflex : Free to all direction : No nystagmus, no diplopia : Round and isokor : +/+ : Not examined

Convergence Reaction

Ophtalmoscopic examination : Not examined

Motoric Tonus Turgor Strength Coordination : Eutonus, tremor (+/+) : Good : Good : Good
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Reflex

: Physiologic (+/+), pathologic (-/-) : No abnormality detected : Good appetite, sleep well : No abnormality detected

Sensibility Vegetative Function Basic Function Specific disorder Rigid Tremor Nasal Stiffness

: None : +/+ : None

Oculogyric Crisis : None Torticolis Others : None : None

Autoanamnesis, July 1th 2013 : Questions Answers Interpretation Cooperative

Herzi, kenalkan ini Lia, ini Iya nggak apa apa, tanya lah widya, boleh kami tanya-tanya Herzi sebentar? Berapa umur Herzi? 23 tahun, tanggal 11 Februari lahir. Udah berapa hari Herzi disini? Dari hari Kamis.

Memorize is good

Time orientation is good

Apa yang terasa sekarang Nggak ada, Cuma lemas aja Herzi? Makan mau nggak? Habis? sedikit. Mau, habis
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Tidurnya gimana? Herzi tahu dimana sekarang?

Tidurnya mulai jam 8 Tau, di rumah sakit jiwa Place orientation is good Discriminative insight is disorder

Kenapa Herzi di bawa kemari? Nggak tau Menurut herzi, wajar nggak Nggak, saya nggak sakit jiwa Herzi di rawat disini? Sama siapa Herzi kesini? Keluarga yang antar, pakai mobil merah, di carter punya orang. Waktu dibawa kesini, Herzi di Nggak ada di ikat, tapi di ikat atau nggak? pasung, kesini. Ada Herzi nampak bayang- Nggak ada. bayang pas masuk kesini? Mendengar bunyi-bunyi aneh Nggak atau suara orang mengomentasi Herzi? Mencium bau bau harum atau Nggak busuk ada nggak? Herzi pernah nggak merasa Iya, dulu merasa seperti Allah, menjadi seseorang? Tanggal berapa? lima hari lagi, tanggal berapa? Udah nikah Herzi? Tanggal 6 Belum berapa ahaha.. sekarang Tanggal 1 bulan Juli tahun sebelum masuk

Pakai apa?

Person orientation is good Situation orientation is good

Visual, akustik and olfactoric hallucination arent present

Dellucion is present

Time orientation is good

Herzi? Bulan apa? Tahun 2013

Apa kerja Herzi kalau di Bantu bantu, kalau ada pokat rumah? ambil pokat, kalau ada kayu ambil kayu.
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Oh iya, Herzi, ini ada dua kertas, satu untuk Herzi tulis, satu lagi untuk bikin gambar, ini penanya.. Boleh cerita boleh buat surat, gambar apa yang ada di pikiran Herzi aja

Gambar gambar apa? Tulis tulis apa?

(mengangguk)

Inisiative is good

Iya lah, makasih ya Herzi, Iya Istirahat lah lagi.

(menggangguk

dan

udah mau kami tanya-tanya. tersenyum)

Alloanamnesis: Allo-anamnesis was given by: Name/Age Address Occupation Relationship with patient : Pendra / 38 years old : Plasma Tiga Klp 54 Jorong Bukit Nilam Aur Kuning, Pasaman Barat (085364092009) : Swasta : Older Brother

Primary couse of hospitalization Patient was nude while running around his home, bother other people, rolling on the heap of rice, always playing toys with a child, feel like a God, talked a lot but incoherent, smiling and laughing alone, restlessness, almost never slept at night, angry for no reason, since two days before hospitalized. Sick for the second time and hospitalized for the first time. The sickness is worse than before. Present complain of patient There is no complaint at this time.
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History of illness: 2011 (forgot month) Patient talked a lot but incoherent, smiling and laughing alone, restlessness, almost never slept at night, but familys patient brougt to indigenous medical practitioner.

2013 (June) Patient was nude while running around his home, bother other people, rolling on the heap of rice, always playing toys with a child, feel like a God, talked a lot but incoherent, smiling and laughing alone, restlessness, almost never slept at night, angry for no reason, since two days before hospitalized. Sick for the second time and hospitalized for the first time. The sickness is worse than before.

Premorbid history Infant : born spontaneously, birth was assisted by midwife, no history of jaundice, cyanosis, and seizure. Childhood Adolescence : : growth and development according to his age. had a lot of friends, easy making new friends and outgoing person, but now because of his condition his friends avoid him

Educational background Elementary School at SD N Lembah Binuang, Pasaman Barat, graduated in 6 years, top ten
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Junior High School at SMP N Lembah Binuang, Pasaman Barat for 1 years, and then continued Pesantren Lembah Binuang for 2 years. Senior High School at MAN Kinali Pasaman Barat, for 1 years. And then continued to MAN Kapri Pasaman Barat until he graduated.

Social economy history Living with his parents, had a permanent house, had a TV and electricity on it, water supply from Municipal Water Corporation, had a motorcycle.

Biological development background Traumas history was present (8 years ago), but not vomiting and was never hospitalized after trauma No history of malaria, typhoid, or brain and neurological disease Consumption drug (dextrometropan once about 30 pils) when he graduated MAN

Family history of illness

There were no family members that has same symptoms like this.

Graphic of illness

201 1

201 3

EXPLANATION AND CONCLUSION OF PSYCHIATRIC EXAMINATION Examination is on July 1st 2013, 2 p.m WIB 1. General appearance Consciousness/sensorial Attitude Motoric Facial expression Verbalization Physic contact Attention Initiative 2. Specific condition A. Affective
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: : : : : : : :

compos mentis/good cooperative active rich speak clearly could be done / appropriate / long enough good good

1. Affective condition 2. Emotional : a. Stability b. Control c. Echt/unecht d. Einfuhlung e. Deep/shallow f. Differentiation scale g. Emotional flow

eutyme

: : : : : : :

stable good enough unecht inadequat shallow narrow fast

B. Intellectual condition of function a. Memory b. Concentration c. Orientation : : : good good enough good can not predicted

d. General and schooling knowledge : e. Discriminative insight f. Intelligence prediction g. Discriminative judgment h. Intelectual deterioration : : : :

disturbed average disturbed none

C. Sensation and perception abnormalities

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1. Illusion 2. Hallucination Acoustic Visual Olfactory Tactile Gustatory

: none : : none : none : none : none : none

D. Thought process condition 1. Speed of thought processs 2. Quality of thought process: a. Clear and sharp b. Circumstantial c. Incoherent d. Sperrung e. Hemmung f. Flight of ideas g. Verbigeration h. Preservation : : : : : : : : clear and sharpless none none none none none none none : fast

3. Thought condition
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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

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

present none none present none none none none much none none none

E. Instinctual drive and behavior abnormalities a. Abulia b. Stupor c. Raptus/impulsivity d. Excitement state e. Sexual deviation f. Echopraxia g. Vagabondage : : : : : : : none none none present, since 2 days ago none none none
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h. Pyromania i. Mannerism j. Others F. Over anxiety G. Reality testing ability

: : : : :

none none none none disturb in behavior, feeling and thinking

MULTIPLE AXIS RESUME Axis I. Clinical Syndrome Patient was nude while running around his home, bother other people, rolling on the heap of rice, always playing toys with a child, feel like a God, talked a lot but incoherent, smiling and laughing alone, restlessness, almost never slept at night, angry for no reason, since two days before hospitalized. Sick for the second time and hospitalized for the first time. The sickness is worse than before. Phsyciatric examination: General Appeareance: compos mentis, cooperative, active, rich, can speak clearly, psychic contact could be done, appropriate and long enough. Specific condition: a. Affective condition: eutiyme, stable, good enough, unecht, inadequate, shallow, narrow, fast. b. Intellectual condition and function: good memory, concentration is good, good orientation, absent intelectual deterioration, discriminative insight and judgment are disturbed. c. Sensation and perception abnormalities: no illusion, no hallucination.

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d. Thought process condition: fast, clear and sharpless, central pattern present, delusion present, much. e. Instinctual drive and behavior abnormalities: excitement state is present, since 2 days ago, decrease since hospitalized. f. Overt anxiety: none g. Reality testing ability, disturbed: behavior, feeling and thinking Axis II : Personality Disorder and Mental Retardation Disorders Personality: outgoing, has a lot of friend but now because of his condition his friend avoid him. Mental retardation: none Axis III : General Medical Condition Traumas history was present No history of malaria, typhoid, or brain and neurological disease Consumption drug (dextrometropan once about 30 pils) when he graduated MAN

Axis IV : Phsychosocial Stressor and Environment Patients had social problems with his friend Axis V: Global Assessment of Function Social relationship couldnt be done since sick Spending time with watching TV, travelling, couldnt be done since sick

MULTIPLE AXIS DIAGNOSIS I. F.20.1 Schizofrenia Hebefrenic

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II. III. IV. V.

No Diagnosis. Consumption drug (dextrometropan once about 30 pils) and traumas history Social and environment problem GAF 60-51 (symptom moderate, disability moderate)

DIFFERENTIAL DIAGNOSIS I. II. F 31.6 Bipolar Affective Disorder Manic Episode with the psikotic symptom F 25.0 Manic type schizoaffective

THERAPY Risperidon 2 x 2 mg Merlopam 1 x 5 mg

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

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