I.

II.
III.

PERSONAL INFORMATION
PSYCHIATRIC HISTORY
MENTAL STATE EXAMINATION
A. General Description
1. Appearance
A female, appropriate to her age, wear full hospital uniform, good self
grooming.
2. State of Consciousness
Clear
3. Speech
- Quantity : Increase
- Quality : Decrease
4. Behavior
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Stereotypy

Mannerism
Automatism
Bizarre
Command
automatism
Acathysia
Tic
Somnabulism

Psychomotor
agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia

Cooperative
Infantile
Distrust
Labile
Rigid

Passive
negativism
Catalepsy
Cerea flexibility
Excitement

5. Attitude
Non-cooperative
Indiferrent
Apathy
Tension
Dependent

6. Connection
Attention easily attained, sustained concentration
Attention easily attained, unable to sustain concentration
Difficult to attain attention, unable to sustain concentration
B. Mood & Affect
1. Mood :
a. Dysphoric
b. Elevated
c. Euphoria
d. Expansive
e. Irritable
f. Cant be assessed
2. Affect :
a. Appropriate

b.
c.
d.
e.
f.

Inappropriate
Restricted
Blunted
Flat
Labile

C. Perception
1. Hallucination
a. Auditory (+)
b. Visual (+)
c. Olfactory (-)
d. Gustatory (-)
e. Tactile (-)
f. Somatic (-)
g. Undiferrentiated (-)
2. Illusion
a. Auditory (-)
b. Visual (-)
c. Olfactory (-)
d. Gustatory (-)
e. Tactile (-)
f. Somatic (-)
g. Undiferrentiated (-)
3. Depersonalization : (-)
4. Derealization : (-)
D. Thought
1. Thought Progress
a. Quantity
- Logorrhea
- Blocking
- Remming
- Mutism
- Talkactive
- Lack of ideas
b. Quality
- Irrelevant answer
- Incoherence
- Flight of idea
- Confabulation
- Poverty of speech
- Slow speech
- Loosening of association
- Neologisme
- Circumtansiality
- Tangential

- Verbigrasi
- Perseverasi
- Sound association
- Word salad
- Echolalia
2. Content of Thought
Idea of Reference
Preocupation
Obsession
Phobia
Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hipokondry
Delusion of magic-mystic
Fantasy

Delusion of Grandiose
Delusion of Control
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Thought of Echo
Thought Insertion
Thought of withdrawal
Thought Broadcasting
Cant be assesed

3. Form of Thought
a. Realistic
b. Non Realistic
c. Dereistic
d. Autistic
E. Sensorium and Cognition
1. Level of education
: unknown
2. General knowledge
: poor
3. Orientation of time/
place/people/situation
: good
4. Working/short/long memory : poor
5. Writing and reading skills
: poor
6. Visuospatial
: poor
7. Abstract thinking
: poor
8. Ability to self care
: poor
F. Impulsivity
1. Self control
:good
2. Patient response to examiners question :good
G. Insight
1. Impaired insight
2. Intellectual Insight
3. True Insight
IV.

PHYSICAL EXAMINATION
A. Status Localis
General Observation
- Consciousness : compos mentis

Vital sign:
Blood pressure
: 120/80 mmHg
Pulse rate
: 80 x/mnt
Temperature
: afebris
RR
: 20 x/mnt
Head-neck
: CA (-), SI (-), lnn ttb
Thorax :
Lung : Vesicular (+/+)
Cor : S1-2 normal, regular
Abdominal
: Peristaltic normal, no tenderness
Extremities
: Normal

B. Neurogical Status
-

Motoric : Normotonus, good coordination of movement

Meningeal sign : negative

Physiologic reflex : +/+

Pathologic reflex : -/1. Physiologic Reflex

- Upper extremities :
right : biceps reflex (+), triceps reflex (+), brachioradial (+)
left : biceps reflex (+), triceps reflex (+), brachioradial (+)
- Lower extremities :
right : patella reflex (+), Achilles reflex (+)
left : patella reflex (+), Achilles reflex (+)
2. pathological Reflex
- Upper extremities :
right : Hoffman Trommer (-)
left : Hoffman Trommer (-)
- lower extremities :
right : Babinski (-), Chaddock (-), Gordon (-), Oppenheim (-),
Rossolimo (-)
left : Babinski (-), Chaddock (-), Gordon (-), Oppenheim (-),
Rossolimo (-)
3. Motor system
Motoric examination
a) Deltoid muscle
b) Pronator muscle
c) Biceps muscle
d) Triceps muscle
e) Wrist-extensor muscle
f) Finger-flexion
g) Finger-abduction

h) Thumb-opposition
i) Hip-flexion
j) Hip-adduction
k) Hip-abduction
l) Hip-extension
m) Knee-extension
n) Hamstring muscle
o) Ankle dorsiflexion
p) Ankle plantarflexion
q) Musculus extensor hallucis longus
4. Sensoric examination
a) pain and light touch sensation : normal
b) Position sense : normal
c) Stereognosia : normal
d) Extinction : normal
5. Range of Movements (ROM)
1. carpal metacarpal : normal
2. metacarpal ohalangeal : normal
3. interphalanx : normal
6. meningeal sign
- Kernigs sign (-)
- Brudzinski I (- Brudzinski II (-)
Recommended examination :
Complete blood count, urynalisis and blood glucose level is recommended.
9.multiaxial diagnosis

V.
VI.

VII.
VIII.

IX.

SYMPTOMS FOUND
IMPAIRMENT
role function : poor
- social function : poor
- spare-time management : poor
- Grooming : poor
SYNDROM FINDINGS
DIFFERENTIAL DIAGNOSIS
F20.0 Schizophrenia Paranoid
F20.5
Schizophrenia Residual
MULTIAXIAL DIAGNOSIS
Axis I
:F
Axis II
: R46.8
Axis III
: No diagnosis
Axis IV
: Unrequited love

X.

Axis V
: GAF admission 40-31
MANAGEMENT PLAN