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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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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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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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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
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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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