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7/28/2019 BST ka ria+tri

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Case Presentation

A 28 years old woman was admitted to HB Saanin emergency unit on September 29th, 2011 at

8 p.m and escorted by his family. This patient was permitted to hospitalize by dr. Fadil. Sick for

the third time and hospitalized for the third time. The sickness is worse than before.

Patient identity:

Name and Age : Etmayeni / 28 years old

MR : 66976

Gender : Female

Place and date of birth : Pesisir Selatan,July 1st1983

Marital status : Married

Address : Tanjung Merdeka, Indrapura Utara Pesisir Selatan

Occupation/School : No Occupation/Senior High School Indrapura

Religion : Muslim

Citizen : Indonesian

Tribe : Minangnese

Allo-anamnesis was given by:

Name/Age : Sawir / 38 years old

Address : Tunggul Hitam (075131422)

Occupation : Enterpreneur

Relationship with patient : Cousin

A. Internal Status

General appearance : Compos Mentis

Blood pressure : 110/70 mmHg

Pulse : easily palpable, regular, 74x per minute,

Respiration : abdominotorakal pattern, regular, 17x per minute

Temperature : 36,80C

Body Shape : astenikus

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Height : 150 cm

Weight : 43 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 (September, 30th 2011)

Hemoglobin : 11,5 g/dl

Leukocyte : 7400/mm3

Thrombocyte : 250.000/mm3

Diff Count : 0/0/1/73/22/4

Autoanamnesis, November 20th 2011 :

Questions Answers Interpretation

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4/16

Assalamualaikum ni,,

Uni siapa namanyo?

Waalaikumsalam

Etmayeni

cooperativePanggilan ibu sia?

Baa kaba ibu kini?

Et

sehat

Lai lamak makan?

Siang ko alah makan tadi?

Lai

alah

Lai lamak lalok ni? lai

Lah bara lamo uni disiko? Lah lamo

Samo sia uni dulu dibawakasiko?

Jo amak, keluarga

Oh iyo uni, baa caritonyo

sampai uni dirawat disiko,

caritoan la ka kami,,

Mmm,,,(pasien senyum)

Baa uni lai wajar uni dirawat

di siko?

Bilo awak pulang buk???

Ee alun buliah lai tanyo kadokternya besok yo

Yo buk

Lai tau dima iyet kini? Di rumah sakit

Bara urang iyet badunsanak? Rami, kakak awak hebat ma,

inyo punya penghasilan 1

miliar (ha,,ha,,pasien senyum)

Yo bana tu? Iyoo..

Rumahnyo gadang, rancak..

Pitih awak banyak juo ma

Lah manikah iyet? alah

Dima suami kini? Di kampuang

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Anak alah ado? Alah,,

Dimanyo kini? Di rumah

Samo sianyo? Jo ibu

Lai tarakak iyet jo inyo lai

Kalo lah pulang bisuak ko jan

marabou-rabo juo ka ibu jo

anak ndak

Ndak buk,,(senyum)

Dulu tu ado masalah iyet

sampai marabou ka ibu jo

anak?

Ndak ado do buk

Tu baa ko marabo se? Hmmm,,

Ada yang menyuruh

/membisikkan ka talingo ga?

ndak

Ado Nampak bayangan ga

yet?

lai

Siapo tu? Wajah kakak

Ado yang dikecekkannyo ka

iyet?

lai

Waktu itu lai di pegangnyo ga

iyet?

lai

Lai pandai iyet manggambar,

buek gambar di karate ko

yo,,suret jadih juo,,

Ayolahh Yet,,

Ee,,ndak bisa do buukk

Ndak tau do bu mau buek

gambar apo,,

E malu iyet, jan dibaco beko

yo,,

Aman tuu E malu iyet a,,(setelah itu

pasien melemparkan tulisan

yang dibuatnya, lalu lari ke

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Makasih yaa niii,,,,

kamar karena malu)

Alloanamnesis:

Primary couse of hospitalization

Patient was restless, knocking her head to the wall, harm her mother and her daughter. She

used to naked, destroying household appliances, often threatening, talkative, smiling and

laughing alone, almost never slept at night, inconsequential, irritable, suspicious of others,

since 1 months before hospitalized.

Present complain of patient

There is no complaint at this time.

History of illness:

2003

Patient was going to Bintan for 2 years work as at an employee. Patient was unsatisfied with

her salary and decided to quit and applied to be a bank employee. But she failed the test and

felt desperate then going insane, talkative, smiling and laughing alone, almost never slept at

night, inconsequential, irritable, suspicious of others. Patient was brought home to Pesisir

Selatan and admitted to voodoo, but theres no respond through this treatment. Patient was

going more insane, irritable, attacking her mother cause thinking she was an evil. Patient

admitted to HB Saanin hospitalized for 2 months and patient went home in a state of calm

and on a regular basis.

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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.

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)

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8/16

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.

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

Educational background

Elementary School at Indrapura, graduated in 6 years

Junior High School at Indrapura, graduated in 3 years

Senior High School at , graduated in 3 years, graduated in 3 years

Marital history

Married at 2005, have one daughter,dan meninggalkannya pada tahun 2008 karena tidak

tahan dengan kelakuan pasien

Social economy history

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9/16

Living with her parents, had a semi permanent house, had a TV and electricity on it, water

supply from well, had no home-phone, had no a motorcycle. Her parents have occupation is

farmer. He got money from her older sister. Usually, Rp. 20.000/day, and she feels not

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

Family history of illness

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

Graphic of illness

9

Drug Withdrawalalcoholic historydapekonomi keluagaya, lalu lari ke kamar karena

malu


10/16

EXPLANATION AND CONCLUSION OF PSYCHIATRIC EXAMINATION

Examination is on November 19th 2011, 1 p.m WIB

1. General appearance

Consciousness/sensorial : compos mentis/good

Attitude : cooperative

Motoric : active

Facial expression : in appropriate

Verbalization : speak clearly

Physic contact : could be done / inappropriate / long enough

Attention : not good enough

Initiative : not good enough

2. Specific condition

A. Affective

1. Affective condition : flat

2. Emotional :

a. Stability : unstable

b. Control : not good enough

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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 : not good enough

b. Concentration : not good enough

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 : present, since 3 month ago lost in last 7 days

Visual : present, since 3 month ago lost in last 7 days

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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 enough and sharp enough

b. Circumstantial : none

c. Incoherent : present

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, have much money and treasure

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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 : present

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

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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.

Phsyciatric examination:

General Appeareance: compos mentis,cooperative, active, in appropriate, speak clearly, Physic

contact could be done / inappropriate / long enough

Specific condition:

a. Affective condition: flat, unstable, Control not good enough, echt, inadequat, shallow,

narrow, fast

b. Intellectual condition and function: Memory not good enough, Concentration not good

enough, Discriminative insight disturbed, Discriminative judgment disturbed

c. Sensation and perception abnormalities: acoustic and visual hallucination present since 3

month ago, lost in last 7 days.

d. Thought process condition: fast, clear and sharp clear enough and sharp enough,

Incoherent present, delution present (have much money and treasure)

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e. Instinctual drive and behavior abnormalities: Abulia present, Excitement state

present, since 3 month ago, decrease in the last 1 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 absent

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

Axis IV : Phsychosocial Stressor and Environment

Merasa terbebani oleh pekerjaan, merasa bertanggung jawab terhadap ekonomi keluarga,

putus obat.

Axis V: Global Assessment of Function

Dayli activity as eating, taking a bath couldnt be done since sick

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.

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III. No Diagnosis

IV.

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

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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