Professional Documents
Culture Documents
By
Preceptor
: Husnul Khotimah
P1555
Yestria Elfatma
R1556
DEPARTMENT OF PSYCHIATRY
MEDICAL FACULTY OF ANDALAS UNIVERSITY
GENERAL HOSPITAL OF M.DJAMIL PSYCHIATRI HOSPITAL
HB SAANIN
PADANG
2015
I.
IDENTITY OF PATIENT
0
Name
Sex
Age
Religion
: Mrs. Y
: Women
: 49 years old
: Moslem
Ethnic
: Minangkabau
Last education
Job
: Housewife
Marriage
: Married
Address
HISTORY OF PSYCHIATRY
Data was get by :
Autoanamnesis on March 11th, 2015.
A. Chief Complaint
The patient came to hospital for a monthly routine check up.
B. Recent History
In March 2015,
Patient come to hospital because she felt a headache, palpitations,
anxiety, easy to cry and get trouble for sleeping. Patient got medical
treatment in polyclinics M. Djamil Hospital.
C. Previous History
1. Psychiatry disorder history
In 2007 (patient forgot the month and the date of the onset)
Patient complaint anxiety, palpitations, and headache. This complaint
has been triggered when she remember her child, but she still can
controlled it and she still do activities as usual.
In 2009 (patien forgot the month and the date of the onset)
Patient always felt a headache, palpitations, and often felt anxiety.
The patient also felt sad, lack to sleep and easy to cry when anxious.
It was triggered when their children were not home.
1
Explanation :
patient
: Man
: Woman
: Patient
: living with patient
: Moderete ill
: Composmentis
: 120/80 mmHg
: Regular, strong lift, frequency 83
times/minute
Respiration
Respiratoric System
Inspection : Simetric statically and dinamically
Palpation : Fremitus similar between left and right chest
Percusion
Neurologic Status
GCS
: E4M6V5
Meningeal Sign
: absent
Extrapiramidal sign
V.
Hand tremor
: present
Akatisia
: absent
Bradikinesia
: absent
Way of stepping : normal
Balance
: non disturbed
Rigiditas
: absent
Motoric
:
freely in any direction
555 555
Sensorik
: well propioseptif and exteroseptif
555
555
Refleks
: Phisiologic reflex (++/++), phatologic reflex (-/-)
Mental Status
Autoanamnesa
Pertanyaan
Jawaban
Siang bu. Ambo dokter Lai
Interpretasi
Compos mentis
Yurli
Dari rumah
Piai, caliak se di status
Personal orientation
intact
ado ma
Oohh
iyo..Bara
umua 49 tahun
Good memory
ibuk kini?
Lai takana tahun bara Tahun 2015
kini buk?
Bulan apo kini buk?
Bulan maret
Kalau tanggal lai takana Tanggal 11
dek ibuk?
Manga ibuk kasiko?
Manambah ubek
Sakik ibuk?
lai kurang
Dek apo ibk cameh?
Ndak jaleh se do
Tu apo yang taraso dek Ibo se ati ko
Good discriminative
insight
tu
ibuk lai?
manangih se lai
Dek apo biasonyo ibuk Ndak lo jaleh dek apo
sadiah sampai manangih do
tu?
Tu
manga
manangih?
Apo
ibuk pikian?
manangih se lai
Emang manga anak ibuk Yo kadang anak alun
tu?
pulang
lai
kan
tu
cameh
Jam bara biasonyo anak Jam 9 alah pulang
ibuk talambek pulang?
mah
Tu apo yang ibuk Karajo, ibuk ndak lo
camehan?
Anak
sekolah
ibuk
manangih lo
Baa kok manangih ibuk Iyo cameh se ibuk kok
anak pai sekolah? Itu baa baa anak dilua,
sekali sekali se atau acok tiok hari, satiok anak
buk?
tp
lai
ibuk
5
alihkan
kadang
karajo-karajo dirumah
(sambil
menghapus
airmata)
Tapi kan lai ndak ado Lai indak
apo-apo yang tajadi sm
anak ibuk kan?
Tu kalau anak lengkap Kalau
dirumah
Tu
menurut
ibuk
cameh
juo
ibuk
cameh
lai
taruih
Good discriminative
judgment
mancubo mengalihkan
jo Jantuang ko berdebar-
ba lamo, tp patang
alah baranti barubek
dek
alah
lamak
rasonyo,
ubek
kok
paralu
dibali
se
sorang,
kini
alah
Sejak
alah
minum
sabalunnyo
payah,
tajago-jago
malam
Ho berati alah lamak Lai makan bantuak
lalok
ibuk
yo,
ibuk Indak
mandanga-danga suarosuaro?
Atau
Nampak
baying-bayangan?
Kok mancium baun- Indak juo do
baun?
Raso
ado
mamacikan
yang Ndak
ibuk
ado
ndak?
Menurut ibuk, ibuk ado Ndak
maraso punyo kehebatan
dari yang lain ndak?
Ado ibuk maraso
kecek-kecekan
No acustic,
di Ndak
sm
urang?
Ibu, pernah maraso ndak Ndak
No Greatness
Delutional
No Suspicious
Delutional
Inferior feeling (-)
baguno?
Tu apo yang araso lai Alah itu se nyo
ibuk?
Berati yang taraso dek Iyoo
ibuk kini -acok camehcameh,
sadih
tu
kontrol
yo
tu
tanang-tanang se pikiran
tu buliah ndak cameh
ibuk, kan anak ibuk lai
elok-elok se. buliah ibuk
bisa tanang bisa lalok
ndak pakai ubek lai yo.
Yo makasi yo buk alah Pulang lai
nio kami tanyo-tanyo,
kama ibuk siap ko lai?
Ha yo lah sekali lai Yo nak
samo-samo
: Composmentis
Attention
: low
Attitude
: Cooperative
Inisiative
: bad
Motoric behaviour
: hypoactive
Facial expression
: poor
Physical contact
: a. Stability
: labil
8
b. Control
: controlled
c. ech unecht
: echt
d. einfuhlung ( invoelaarhaid )
: inadequate
e. deep-shallow
: shallow
f. differentiation scale
: narrow
g. emotion flow
: slow
B. Intelectual Funnction
a. Memory (amnesia)
: not good
b. Concentration
: not good
c. Orientation
( time, spatial, personal, situation)
: disturbed
d. general knowledge
: difficult to evaluate
e. discriminative insight
: disturbed
: cannot evaluated
g. discriminative judgment
: disturbed
h. intelectual deterioration
: absent
: absent
- acustic
: absent
- visual
: absent
- olfatorik
: absent
- tactil
: absent
D. Way of Thinking
1. Psikomobilitas
: slow
2. Thingking process
a. clear and sharp
b. Sirkumstansial
: absent
a. Inkoherrent
: absent
b. Sperrung
: absent
c. Hemmung
: absent
9
d. Flight of ideas
: absent
: absent
3. Contents
a. Central pattern
: absent
b. Phobia
: absent
c. Obsess
: absent
d. Dellusion
: absent
e. Suspicion
: absent
f. Confabulation
: absent
g. Animosity/revenge
: absent
h. Inferior feeling
: absent
i. Much/less
: less
j. Guilty feeling
: absent
k. Hippochondria
l. Others
: absent
:-
: absent
b. Stupor
: absent
c. Raptus / impulsivitas
: absent
d. excitement state
: absent
e. sexual deviation
: absent
f. Echophraxia
: absent
g. Vagabondage
: absent
h. Piromani
: absent
i. Mannerisme
: absent
j. Others
:-
F. Overt anxiety
: no
G. Relation to reality
absent.
Sensation and perception disorder: illusion and hallucination absent.
Process of Thinking: slow, unclear and not sharp, circumstancial,
incoherrent, Sperrung, Hemmung, flight of ideas, verbigeration, central
pattern, phobia, delusion absent, suspicion absent, confabulation,
animosity and revenge, inferior feeling, less, guilty feeling, hypochondria
are aabsent.
Instinctual encouragement: abulia absent, stupor absent, raptus absent,
excitement state absent, sexual deviation absent, echophraxia absent,
MULTIAXIAL DIAGNOSIS
II
III
IV
V
Symptomps
No diagnosis
No diagnosis
Problem with primary support group (family), job, and economics
GAF 50-41
DIFFERENTIAL DIAGNOSIS
1. F33.8 Another Recurrent Depressive Disorder
2. F33.9 Recurrent Depressive Disorder Unspecified
3. F25.1 Depressive Type of Schyzoafektive Disorder
THERAPY
A. Pharmacotherapy :
B. Psychotherapy :
1.
Patient
Supportif psycotherapy
Psychoeducation
Onset
Relaps
Diagnosis
Assesment
Adult
Often
Recurrent
Depressive
Disorder
with
Good
Bad
Severe
Family Support
Medicine
Bad
Good
Respons
Marriage
Economy
Divorced
Moderete
to Dicipline
Condition
Obedience
take medicine
Trigger
Genetic
Penyakit
problem
Nothing
lain/ Nothing
gangguan lain
Quo ad vitam
: bonam
Quo ad fungsionam : bonam
Quo ad sanationam : dubia ad bonam
The thing that can make good prognosis : onset, medicine respons, economy
condition, obedience to take medicine, genetic, and no other disease and disorder.
The thing that can increase bad prognosis : relaps, diagnosis, family support,
divorced, and the trigger.
XII. CASE ANALYSES
The diagnosys of the patient got from medical history and physical
examination. Patients chief complains anxiety that happen everyday in more than
six month. She also felt palpitation, headache, get a trouble for sleep and easy to
cry. She doesnt has drunk history and using drug history. Physical examination
shows normal blood pressure of 120/80 mmHg. Cardiovascular, respiratory,
gastrointestinal, and neurologic examination shows no abnormalities.
According to PPDGJ III, if anxiety symptoms showed everyday for several
weeks until month and its free floating. Patients felt something bad luck was
happen to her child. She also felt tremor, palpitation and headache, so it can be
diagnose comphrehensive anxiety disorders.
13
14
2009
Anxiety,
palpitation,
headache, get
trouble to sleep,
and easy to cry,
everyday
2013
Getting better
2011
Her complaint
more decreased
2015
Her complaint was
return and she go to
polyclinic M. Djamil
Padang
2012
getting better
2010
The first time she
get thepary she felt
the symptoms
decreased
2014
Getting
better, and
she stop to
medical
check up