Professional Documents
Culture Documents
OLEH:
REDO AGUSTA
P. 1794 B
P. 1801 B
KEVIN MAULANDA
P. 1812 B
PEMBIMBING:
dr. YaslindaYaunin, Sp.KJ
BAGIAN PSIKIATRI
FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS
RSUP DR. M. DJAMIL PADANG
2016
1
CASE REPORT
A 66 years old male patient was brought by his family from psychiatry polyclinic to the
psychiatrys ward of RSUP Dr. M. Djamil Padang on April, 14 2016 at 5.13 am
I.
IDENTITY OF PASIENT
Name
Mr. O
Sex
Male
Age
66 years old
Marriage status
Married
Religion
Moeslim
Occupation/School
Coconut farmer
Citizen
Indonesian
Tribe
Minangnese
Address
II.
HISTORY OF PSYCHIATRIC
Alloanamnesis with Mr. E/ 25 years old/ live at same place with patient (biological son)/
at Padang on April, 20th 2016 at 4.45 pm
A. Chief Complain
Patient got angry and rowdy since 15 days ago.
B. Main Reason
Patient got angry, rowdy and tried to hit people surrounding him. Patient also threw
goods to other people since 10 days ago.
C. History of Present Illness
-
The patient got angry, rowdy and tried to hit people surrounding him. Patient also
threw goods to other people since 10 days ago. The patient got angry because his son
tried to unpack his own huts door for replacing his sons cowsheds.
2
He tried to hit people because he thought that other people was gossiping him. He
couldnt stop himself from it because he felt that his mind was full, so that he
wreaked it by hitting others.
He also felt suspicious with other people and thought that they tried to put ghost into
his body.
He smelled kemenyan smell 15 days before his admission until he came to the
hospital. After inpatient, the smell was absent.
He didnt obey the schedule to take medications during his time in home. Patient felt
that the medications taken were too big and not the same with the medications he got
from the hospital
He has been smoking for more than 40 years, approximately 2 packs per day.
He didnt lose appetite, never feel sad. Sleeping time was adequate. There is no
withdrawal acts from society.
The patient didnt feel any fear of being in the crowd, of being humiliated by the
crowded people, of something that actually it never happens.
b. In 2012
In 2012, he got angry and rowdy with his sons act. His son was unpacking the
doo, but the patient thought that his sons act was useless and no reason. He also
often talked alone when people was not around him. He was hospitalized for 22
days in RSUP Dr. M. Djamil. He went home after doctors allowance. He took
medications regularly (he remembered how many types, but forgot the name and
color).
2. History of Medical Disorders
There is no history of head injury, neurological, metabolic, infection problems and
other associated organ failure
3. History of Consuming Alcohol and Other Addictive Substances
The patient has been smoking for more than 40 years ago, 2 packs per day. There is
no history of consuming narcotics and other addictive drugs.
4. History of Personal Life
a. Perinatal and prenatal
The partus process was normal, the baby was mature, health condition during
pregnancy was good, the emotion during pregnancy was good. During pregnancy
the mother didnt consume any kind of drugs.
b. Early child period
Patients growth and development were normal and same with other kids. There is
no history of behavior disorder in this period.
c. Mild child period
There is no learning disorder. Social interaction is normal. Patients growth and
development wee normal and same with other kids. Patient had many friends.
d. Late children and teenager
There is no history of psychosexual disorder.
e. Adult period
-
Educational Background
Patient only studied until 2nd year of elementary school.
Occupational Background
4
Marriage History
Patient has married with his wife since 1976.
Religion History
Patient knew know well about Islam. He was quite routine in doing prayers.
Psychosexual History
There is no history of sexual abuse or sexual disorientation.
Social Activity
In some time, the patient easily to get along, others so irritable cheerful. In
other condition patient dont want to have communication to others.
Lawlessness History
There is no history of lawlessness, criminal issue, and arrested
E. Family History
Description:
= Pasien
= Pria
= Wanita
There were no family members that has same symptoms of this mental disorder
III.
INTERNAL STATUS
General condition
Awareness
: Composmentis
Blood pressure
: 120/70 mmHg
Pulse
Respiration
Temperature
: 36,80C
Height
: 168 cm
Weight
: 58 kg
Nutritional status
: normoweight
Cardiovascular system :
Inspection
Palpatiom
Percussion
Auscultation
Respiratory System
Inspection
Palpation
Percussion
Auscultation
IV.
NEUROLOGICAL STATUS
GCS
: 15 (E4M6V5)
Meningeal Signs
: None
Ekstrapiramidal sign
- Hand tremor
: absent
- Akatisia
: absent
- Bradikinesia
: absent
- Way of stepping
: normogait
- Balance
: not disturbed
- Rigiditas
: absent
- Power
: 555 555
555 555
- Motoric
- sensorik
V.
MENTAL STATUS
Autoanamnesa
Questions
Answers
Assalamualaikum pak
Waalaikum salam
Interprestation
Composmentis
Oden
Personal orientation intact
66 tahun
19
Padang,
Dr.M.Djamil padang
Selasa
2015
RSUP
Time
and
place
orientation is disturbed
Dibaok keluarga
perasaan gelisah lo
apo
sampai
Behaviour disorder
mabuek
berang-berang?
kandang jawinyo
Thought disorder
Pas
apak
berang
manokok urang tu, tau ndak maaraso awak ndak salah kan
itu perilaku yang salah, tu urang-urang tu nan salah ma,
pas berang-berang tu a nan pas berang-berang tu awak
taraso dek apak
Allenged level
kini?
intelligency good
dan
lai
lamak pak
rasonyo pak?
Kini baa perasaan apak?
Discriminative insight is
disturbed
itu,
mandanga
ado
bisiak-bisiakan
buk?padohal
ndak
ado
urangnyo buk?
Ooo...kalau
bau-bauan?bau
apak
balabiahan?
Berdebar-
No anxiety
debar?
Ado apak maraso sadiah Ndak ado do
akhir-akhir ko ?
Ado apak maraso bersalah Ndak ado do
?
No depression
buk ?
Pernah apak maraso ndak Ndak ado do
baguno ?
Discriminative judgement
is not disturbed
pulang
beko
sebelumnya
composmentis/good
Attitude
cooperative
Motoric behaviour
hyperactive
Facial expression
rich
Verbalization
speak clearly
Psychical contact
Attention
good enough
Initiative
good enough
hiperthym
2. Emotional :
a. Stability
labil
b. Control
c. Echt/unecht
echt
d. Einfuhlung
inadequate
11
e. Deep/shallow
shallow
f. Differentiation scale
narrow
g. Emotional flow
fast
a. Memory
less
b. Concentration
disturbed
c. Orientation
disturbed
personal,
and
place
orientations.
d. General knowledge
difficult in value
good
f. Discriminative insight
level 1
g. Discriminative judgment
good
h. Intellectual decreasing
none
: none
2. Hallucination
Acoustic
: none
Visual
: none
Olfactory
: yes
Tactile
: none
Gustatory
: none
fast
2.
b. Circumstantial
none
c. Incoherent
none
d. Sperrung
none
12
none
f. Flight of ideas
none
g. Verbigeration
none
h. Preservation
none
a. Central pattern
none
b. Phobia
none
c. Obsession
none
d. Suspicion
none
e. Delusion
none
f. Confabulation
none
g. Dominance, animosity
yes
h. Inferior feeling
none
i. Much / little
much
j. Guilty feeling
none
k. Hypochondria
none
l. Others
none
3.
e. Hemmung
Thought condition
none
b. Stupor
none
c. Raptus/impulsivity
none
d. Excitement state
yes
e. Sexual deviation
none
f. Echopraxia
none
g. Vagabondage
none
h. Pyromania
none
i. Mannerism
none
j. Others
none
13
F. Over anxiety
none
B. Axis II
Based on personality history, there is no personality and mental disorder on patient founded
yet.
14
C. Axis III
There is no another medical problem with this patient.
D. Axis IV
There are problem with primary support group.
E. Axis V
The patient had mild symptom and settle, mild disability in funtion, and overall still good in
general, so the GAF score was 70-61
VII.
MULTIAXIAL DIAGNOSIS
I.
F31.2 Bipolar Affective Disorder at Present Manic Episode with Psychotic Symptom
II.
No diagnosis yet
III.
No diagnosis
IV.
V.
GAF 40-31
IX. THERAPY
A. Pharmacotherapy
-
Risperidon 2 x 2 mg
Merlopam 1 x 0,5 mg
Haloperidol 1 x 1,5 mg
Vit B complex 3 x 1
Vit C 3 x 1
15
B. Psycotherapy
1.Patient
- Support psycotherapy
- Psychoeducation
- Pharmacotherapy
2. Family : Psychoeducation about patient condition and histherapy
X. PROGNOSIS
Point
Good
Not good
Onset
Adult
Onset of time
Not clear
Family Support
Not good
Marital status
Married
Positive symptom
Exist
disorder
Precipitating factor
Clear
Sosial withdraw
Exist
neurologis Exist
Exist
Others disease
None
Sign
disorder
bonam
Quo ad Functionam
dubia et bonam
Quo ad Sanationam
dubia et bonam
16