BST Buk Linda, Eta Jonni

7/28/2019 BST Buk Linda, Eta Jonni

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Case Presentation

A 33 years old man was admitted to HB Saanin asylums emergency unit on September 11 th,

2011 at 11 a.m and escorted by his family. This patient was permitted to hospitalize by dr.

Fadil. Sick for the fifth time and hospitalized for the fourth time. The sickness is worse than

before.

Patient identity:

Name and Age : Dafit Fernandes / 33 years old

MR : 79902

Gender : Male.

Place and date of birth : Pariaman, September 23th 1978

Marital status : Single

Address : Pancasila Street No. 30 RT 03 RW 01 Sungai Penuh, Kerinci

Occupation/School : No Occupation/Senior High School

Religion : Islam

Citizen : Indonesian

Tribe : Minangnese

Allo-anamnesis was given by:

Name/Age : Armen Filma/40 years old

Address : Sungai Penuh, Kerinci (0811742897)

Occupation : Trader

Relationship with patient : Older Brother

A. Internal Status

General appearance : Compos Mentis

Blood pressure : 120/70 mmHg

Pulse : easily palpable, regular, 81x per minute,

Respiration : abdominotorakal pattern, regular, 21x per minute

Temperature : 36,90C

Body Shape : astenikus

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Height : 180 cm

Weight : 78 kg

Cardiovascular system : No abnormality detected

Digestive system : No abnormality detected

Specific disorder : No abnormality detected

B. Neurological Status

Cranial Nervous (five senses) : Vision, smelling, hearing, tasting, and tactil are well

Meningeal Signs : None

High Intracranial Pressure Signs : None

Eyes

- Movement : Free to all direction

- Perception : No nystagmus, no diplopia

- Pupil : Round and isokor

- Light Reflex : +/+

- Convergence Reaction : Not examined

- Ophtalmoscopic examination : Not examined

Motoric

- Tonus : Eutonus, tremor (+/+)

- Turgor : Good

- Strength : Good

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- Coordination : Good

- Reflex : Physiologic (+/+), pathologic (-/-)

Sensibility : No abnormality detected

Vegetative Function : Good appetite, sleep well

Basic Function : No abnormality detected

Specific disorder

- Rigid : None

- Tremor : +/+

- Nasal Stiffness : None

- Oculogyric Crisis : None

- Torticolis : None

- Others : None

Laboratorium (August, 9th 2011)

Hemoglobin : 11 g/dl

Leukocyte : 8300/mm3

Thrombocyte : 210.000/mm3

Diff Count : 0/0/1/83/12/4

Blood Type : A

Autoanamnesis, November 7th 2011 :

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Questions Answers Interpretation

Assalamualaikum Waalaikumsalam

cooperative

Da Dafit wak Meta, ko Jonni.

Kami nio mamariso Da Dafit.Nanyo-nanyo sabanta

Jadih. Disikolah wak duduak

diak. Bang Dafit santa laipulang mah. O iyo. Salamaik

hari rayo diak. Patang Idul

Adha maa.

O yo. Samo-samo yo bang.

Lai sumbayang bang patang?

Lai. Disiko se sumbayangnyo.

Bia lah. Santa lai bang Dafit

pulangnyo mah. (tersenyum

lebar)

Iyo bang? Sia nan

mangecekan abang buliah

pulang?

Perawatnyo mah. Tapi

keluarga bang dafit alun juo

manjapuik lai. Tingga masalah

administrasinyo se lai mah. Tu

lah. Kawan-kawan ko acok

dicaliak dek keluarganyo.

Bang Dafit indak do. (hening

sejenak)

Personal orientation is good

Bilo terakhir keluarga Bang

Dafit kamari?

Saminggu nan lewat. Time orientation is good

Ha kan baru-baru ko tu mah Eh iyo nak diak (tersenyum

lebar)

Lah bara lamo bang Dafit

disiko?

Mungkin kiro-kiro alah 1,5

bulan mah

Time orientation is good

Dek a Bang Dafit dibawo

kamari?

Antahlah. Padahal Bang Dafit

ndak sakik jiwa dibawo dek

Uda Bang Dafit kamari.

Dikabek lho tu

Discriminative insight is

disorder

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5/18

Baa kok dikabek bang? Yo. Marabo nio pulang.

Manga abang dibawo kasiko.

Abang ndak sakik do.

Keluarga Abang tu nan sakik

mah. Gilo. Bang Davit

dikarajoan dek urang mah.

Keluarga Bang Davit punyo

karajo. Nyo bailmu mah.

Dipamainannyo Bang Dafit.

Bang Dafit dituduah suko

onani bagai. Pamainan poyok.

Ntah apo tu. Ko ndak juo

diurusnyo administrasi pulang

Bang Dafit.

Much, Fast

Bang Dafit ko ado-ado se

mah. Maa pulo keluarga Bang

Dafit punyo ilmu. Maa

amuahnyo mampamainan

Bang Dafit

Ndee Iyo mah diak.

Dituduahnyo ge awak main

poyok, onani. Tu makonyo

kurang lalok Bang Dafit ko

mah. Apolai lampu kamar

koslet. Suaronyo manggaduah.

Baun anguih mah. Lai tadanga

dek adiak. Ndak lamak lalok

Bang Dafit do.

Dellucion is present

Ndak ado tadanga dek kami

do bang

Sakareh tu ha Akustik and olfactoric

hallucination are present

Lah bara lamo tadanga koslettu Bang Dafit?

Sajak disiko. Tapi samingguko lah ndak sakareh biasonyo

tadanga do. Waktu dirumah

listrik koslet pulo mah. Indak

juo dipelokkan uda do

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Ado pernah nampak bayang-

bayang Bang Dafit ndak?

Ha ndak ado do Visual hallucination is absent

Bang Dafit, wak barituang

stek yo. 100 7 bara?

93

Concentration is not good

enough

Kurang 7 liak Hmm86

Kurangi 7 Hmm.74..eh ndak nak.. bara

tadi?

86 - 7 Oo iyo.. hmmm.. 79 nak

Bang Dafit suko pai jalan-

jalan surang? Ndak tantu arah.

Ndak sadar se dima

Ndak do do Vagabondage is absent

Bang Dafit suko mambaka-

baka ndak?

Mambaka saroknyo diak

(tertawa).

Pyromani is absent

Bang Dafit ado maraso takuik-

takuik ndak?

Ndak do Bang takuik do. Bang

Dafit urang bagak mah

Phobia is absent

Raso badoso lai? Ka sia Bang Dafit badoso.

Keluarga tu nyo yang jaek ka

Bang Davit. Dikarajoannyo jo

ilmu. Dituduahnyo gai Bang

Dafit onani, main poyok. Ko

alun juo diurus administrasi

pulang ha

Feeling guilty is absent

Hmm.. Tolong Bang Dafit telponan

Da Men tu ciek. Suruahnyo

maurus administrasi. Japuik

Bang Dafit lai. Bang Dafit ka

pulang lai. Nio basobok jo

kawan-kawan bagai.

Central pattern is present

Kalo Bang Dafit Basobok Bang Dafit ambiak untuak

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7/18

pitih di jalan, apo nan ka Bang

karajoan?

tambahan pitih lanjo

Discriminative judgement is

disorderKan ndak pitih abang tu do

mah. Baa kok baambiak?

Kan lah tacampak mah.

Berarti ndak paralu lai dek

urangnyo

O iyo Bang Dafit. Buek lah

gambar agak ciek. Trus

manulis disiko

Oh jadih

Ha ko lah salasai.

Bang Dafit lai ingek namo

Kami?

Lai. Namo adiak Meta, nan

iko Jonni. Eh Lah jam 4 ha.

Bang Dafit ambiak rokok dulu

yo diak.. Lai buliah kan. Beko

Bang Dafit carito liak.

Memory is good

Yo Bang. Kami ka pulang

pulo lai mah

Pulang lai? Lai di Padang ko

juo tingga?

Lai Bang.. Yo lah.. makasi yo

Bang..

Yo samo-samo.. (tertawa)

Alloanamnesis:

Primary couse of hospitalization

Patient was restless, almost never slept at night, talked a lot, inconsequential, irritable,

suspicious of others, often threatening, like chasing other people, hitting a parked vehicle

with wooden beams, destroying household appliances, since 3 months before hospitalized.

Present complain of patient

There is no complaint at this time.

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8/18

History of illness:

1999 (around October)

Patient were studied at the University of Eka Sakti. GPA of patient is always low and tends

to decrease. 1st semester , GPA was 2.2, 2nd semester , GPA was 1.5, 3 rd semester, GPA was

1.5, and 4th semester, GPA was 1. Patient began to blame the lecturer for the value obtained.

Patient felt that he is always correct in answering the exam questions and tasks. After that the

patient began to forget things. Forgot to create a task, forgot to close the rice and side dishes,

forgot to turn off the lights, stoves, and others. Patient using marijuana in the year, also ever

use a syringe, so patient drop out. Patient become lazy, likes silence, muse, and often looked

sad. Until one day, the patient ran home leaving his nephew for a walk on the grounds

chasing bad guys. When in fact there is no person who intends evil to him. Then the patient

was taken to Puti Bungsu asylum for treatment, and was given outpatient treatment.

2000 (beginning of the year)

After several months of treatment, no installment, the patient was brought back to the Puti

Bungsu Hospital. Patient treated at Puti Bungsu asylum for about 23 days. Patient went home

in a state of calm and on a regular basis. The patient always controlled his present condition

after discharge.

2007 (forgot month)

Patient was restless, angry, always suspicious of other people, hitting a parked vehicle with

wood beams, and lots of talking. Previously, patient was not taking medication regularly

since last year. The patient was taken to Puti Bungsu and treated for about 25 days. Patient

went home in a state of calm and on a regular basis. The patient always controlled his present

condition after discharge.

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9/18

2010 (October)

Patient often visited the house of relatives, neighbours and friends, because that is still in an

atmosphere of Eid. Each visit, patient always asked for were treated with coffee. Until that

day, he drank up to 8 cups of coffee at the shop. Suddenly, throwing his coffee cup on the

floor. From then on, he complained that he could not sleep. Patient was restless, loquacious,

inconsequential, alternation, always felt everything the world mean for him, felt as if by

magic, and complained about short sircuit sound. The patient was taken to the HB Saanin

asylum and hospitalized there about 1.5 months. Patient went home in a state of calm and on

a regular basis. The patient always controlled his present condition after discharge.

2011 (September)

Since early 2011, the patient did not want to take medication because they feel healthy. The

patient began to show abnormalities in June. The patient was restless, almost never slept at

night, talked a lot, inconsequential, irritable, suspicious of others, often threatening, like

chasing other people, hitting a parked vehicle with wooden beams, destroying household

appliances, felt as if by magic, and complained about short sircuit sound. The patient refused

to hospital. Finally Patients family deceived him and took the patient to a HB Saanin asylum

for treatment.

Premorbid history

Infant : born spontaneously, birth was assisted by midwife, no history of

jaundice, cyanosis, and seizure.

Childhood : growth and development according to his age.

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10/18

Adolescence : had a lot of friends, easy making new friends and outgoing person

Educational background

Elementary School at SD N 27 Sungai Penuh, graduated in 6 years, top ten

Junior High School at SMP N 8 Sungai Penuh, graduated in 3 years, top ten

Senior High School at SMA N 1 Sungai Penuh, graduated in 3 years, achievement decreased

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 no home-phone, had a motorcycle. His parents and

him have no occupation. He got money from his older brother. Usually, Rp. 20.000/day, and

he feels enough.

Biological development background

Head traumas history was present, but not vomiting and was never hospitalized after

trauma

No history of malaria, typhoid, or brain and neurological disease

Marijuana abuse and alcoholic history

Family history of illness

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

Graphic of illness

EXPLANATION AND CONCLUSION OF PSYCHIATRIC EXAMINATION

Examination is on November 7th 2011, 3 p.m WIB

1. General appearance

Consciousness/sensorial : compos mentis/good

Attitude : cooperative

Motoric : active

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Facial expression : rich

Verbalization : speak clearly

Physic contact : could be done / inappropriate / long enough

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 : not good enough

c. Orientation : good

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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 : present, since 3 month ago decrease in last 7

days ( hearing short sircuit sound)

Visual : none

Olfactory : present, since 3 month ago decrease in last 7

days (scorch odor)

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

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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 : present

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

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E. Instinctual drive and behavior abnormalities

a. Abulia : none

b. Stupor : none

c. Raptus/impulsivity : none

d. Excitement state : present, since 3 month ago, decrease in

the last 1 and half months

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 restless, almost never slept at night, talked a lot, inconsequential, irritable, suspicious

of others, often threatening, like chasing other people, hitting a parked vehicle with wooden

beams, destroying household appliances, lack of sleep and adequate diet since 3 months before

hospitalized. Sick for the fifth time and hospitalized for the fourth time. The sickness is worse

than before.

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Phsyciatric examination:

General Appeareance: compos mentis, cooperative, active, rich, can speak clearly, psychic

contact could be done, inappropriate 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 not good enough,

good orientation, absent intelectual deterioration, discriminative insight and judgment are

disturbed.

c. Sensation and perception abnormalities: no illusion, acoustic and olfactoric hallucination

present since 3 month ago, decrease in last 7 days.

d. Thought process condition: fast, clear and sharp enough, central pattern present, delusion

present, much.

e. Instinctual drive and behavior abnormalities: excitement state is present, since 3 months

ago, decrease in the last one and half months

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

Mental retardation: none

Axis III : General Medical Condition

Head traumas history was present

No history of malaria, typhoid, or brain and neurological disease

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Marijuana abuse and alcoholic history

Axis IV : Phsychosocial Stressor and Environment

Drug withdrawal

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.31.2 Bipolar Affective Disorder Manic Episode with Psychotic Symptoms

II. No Diagnosis.

III. Marijuana abuse and alcoholic history

IV. Drug Withdrawal

V. GAF 41-50.

DIFFERENTIAL DIAGNOSIS

I. F 31.6 Bipolar Affective Disorder Mixed Episode

II. F 25.0 Manic type schizoaffective

THERAPY

Risperidon 2 x 1 mg

Haloperidol 2 x 5 mg

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THP 2 x 2 mg

PROGNOSIS

Clinical : dubia at malam

Functional : dubia at malam

Social : dubia at malam

SUGGESTION FOR THERAPY

Education to the family

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BST Buk Linda, Eta Jonni