You are on page 1of 30

MUHAMAD AZRUL 0810314158 CHARAN PAL SINGH 0810314156 PRECEPTOR: dr. YASLINDA YAUNIN SP.

KJ

    


  

Name : Sari Bulan Gender : Female Age ` : 29 years old. Marital status : single Address : koto Napan, Sumut Occupation and School : Secondary school, not working Religion : Islam Citizen : Indonesian Race : Minangkabau

A 29 year old female patient was admitted to RSJ HB Sa’anin emergency department on April 26th, 2013 and escorted by her brother. This patient presented with signs such as anxiety, always being angry without reason, always talking to herself without sense, laughs herself even when there is no one around, sometimes she becomes emotional when things doesn’t go on her needs.. She has delusion of greatness and thinks she is a famous artist. She has no problem in her eating habits. She threatened her family members with harsh words

Internal Status General appearance Blood pressure Pulse rate Temperature : : : : Compos Mentis 110/70 mmHg 86 x per minute 36.5 C No disorders found No disorder found No disorder found Cardiovascular system : Digestive system Specific disorder : : .

Neurological Status GCS 15. no disorder. Eutrophic. Muscle strength –superior extremity 555/555. pupil reflex positive. inferior extremity 555/555 Sensibility Specific disorder : : No disorder found No disorder found . corneal reflex positive No meningeal signs. no signs of increased intracranial pressure Cranial nerves Motoric : : No disorders found Eutonus.

ALLOANAMNESIS Was done on 20th May 2013 Alloanamnesis obtained from patient’s brother: Name Age Telephone : Salam : 44 years : : private company Work & Education Relation with patient : brother .

sometimes she becomes emotional when things doesn’t go on her needs. She has delusion of greatness and thinks she is an famous artist. laughs herself even when there is no one around.1.. She threatened her family members with harsh words . always being angry without reason. Main reason of Hospitalization This patient presented with signs such as anxiety. always talking to herself without sense.

threaten her family members with harsh words and was brought to the RSJ HB Saanin and was admitted .Present complaint of Illness Patient classified as Healthy without any complaint 1. always get angry if her need doesn’t go with her desire. History of Illness Year 2006 (Month unidentified) Patient was frequently anxious. Always goes out during the night.

She has been in and out of the hospital for the past 6 years with the same complaints Year 2013 (April till Present) Patient does not want to take regular medications.Year 2007-2012 (month unidentified) The patient was admitted regularly to the hospital for the same complaints She was brought to RSJ HB Saanin and was warded there. . she has delusions of greatness as if she is a famous celebrity. The patients also thinks she has graduated from university and obtained a degree. laughs without any reason. The patient likes shopping.

or seizure. birth was assisted by midwife. Premorbid History Infant : born spontaneously. Childhood : growth and development suitable for her age. cyanosis.3. no history of jaundice. easily make new friends and outgoing person Adult : have a lot of friends . Adolescence: polite. had a lot of friends.

4. Socioeconomical status Lives with her elder brother in a permanent house. good electricity and water resources. Educational Background Primary School : completed primary school Secondary school : completed secondary school 5. with a color TV and motor vehicles. Work history Patient has no working history 6. .

1. Family History ♂ ♀ ♂ ♀ ♀ ♀ ♀ ♂ ♂ ♂ ♂ ♀ ♂ ♀ ♂ ♂ ♀ ♀ ♀ .

Graphic of illness course Years 2006 2007 2008 2009 2010 2011 2012 2013 .

long enough : present : present .Summary of Phsyciatric Examination I. appropriate. General Appearance Counciousness Attitude Motoric Facial expression Verbalization Physic contact Attention Initiative : compos mentis : cooperative : active : good : can talk. clearly and fluently : can be done.

Deep/shallow : shallow  f. Einfulung : inadequate  e.II. Affective 1.Affective condition : hypertym 2. Emotional flow : slow . Echt/unecht : echt  d. Control : controlled  c. Emotional :  a. Specific Condition A. Differentiation scale : narrow  g. Stability : stable  b.

Discriminative judgment : not disturbed . Concentration : enough c. Intelligence prediction : average g.B.        Intellectual condition of function a. Memory : enough b. special and persons orientation good d. Orientation : time orientation good. Discriminative insight : not disturbed f. Knowledge: undetermined e.

C. 2. 1.      Sensation and perception abnormalities Illusion : none Hallucination : Acoustic : none Visual : none Olfactory: none Tactile : none Gustatory: none .

Flight of ideas : present  f. Hemmung : none  e. Quality of thought process:  a. Thought process condition 1.D. Incoherent : none  c. Speed of thought process :clear and appropriate 2. Sperrung : none  d. Verbigeration : none  g. Clear and sharp :clear and sharp  b. Preservation : none .

j. b. h. g. c. e. i.             a. l. f.3. k. Thought condition Central pattern : Phobia : Obsession : Delusion : Suspicion : Confabulation : Repulsion : Inferior feeling : Much/little : Feeling guilty : Hypochondria : Others : none none none none none none none none little none none none . d.

Abulia : none  b. Over anxiety : none  G. Sexual deviation : none  f. Excitement state : none  e. Pyromania : none  i. Stupor : none  c. Reality testing ability : no disturbance . Mannerism : none  j. Raptus/impulsivity : none  d. Echopraxia : none  g. Others : none  F.E. Vagabondage : none  h. Instinctual drive and behavior abnormalities  a.

laughs without any reason.MULTIPLE AXIS RESUME Axis 1. The patients also thinks she has graduated from university and obtained a degree. she has delusions of greatness as if she is a famous celebrity. Clinical syndrome  Patient does not want to take regular medications. . The patient likes shopping.

less initiative. cooperative.talkative. . appropriate.Phyciatric examination  General condition: compos mentis. psychic contact good. hyperactive. long enough. verbalization is clear and sharp.

discriminative insight not disturbed.no hallucination. .Intellectual condition of function: memory good. good concentration. intelligence average.Sensation and perception abnormalities: no illusion .Affective condition: hyperthym. stable. knowledge is difficult to evaluate.Specific condition : 1. echt. time orientation is good. 2. discriminative judgments not disturbed. 3.

circumstantial present. clear and sharp. 5.Reality testing ability : no disturbance in behavior. delusional.Thought process condition: fast. suspicious.4.Over anxiety : none 7.Instinctual drive and behavior abnormalities : no disturbance 6. feeling and thinking .

Personal disorder and mental retardation disorder  Personality disorder : none  Mental disorder : none Axis III. General medic condition  No history of head trauma .Axis II. . or malaria which needed hospitalization.

Psychosocial stressor and environment  None Axis V.Axis IV. .  Leisure/ recreational activity: no disturbance. Global assessment functional  Social: likes shopping and going out at night  Daily Activity: no disturbance.

Multiple Axis diagnosis  I . . No problems  V . F31. No Diagnosis  IV. Manic Episode with psychotic symptoms  II. No Diagnosis  III.2 Bipolar Affective Disorder.

31 Organic Bipolar Affective disorder Therapy  Chlorpromazine 1 x 1 tablet @ 100 mg  Risperidone 1 x 2mg .8 Other Bipolar Affective disorders  F 06.Differential diagnosis  F 31.

Prognosis  Clinical : dubia ad bonam  Functional : dubia ad bonam  Social : dubia ad bonam .

susah. bisikan. hidungnya mancung Bisa abang Baru selesai mandi Makan alun siang alah. mencium bau? Saya sakit jadi keluarga berobat Tidak ada bang . Tidak bias belajar. Concentration is good . Teman kamu ganteng sekali. Orientation is not disturbed Kenapa bias sampai disini? Baa tu? Sering ngak kedengaran suara suara. Nampak bayangan.Autoanamnesis Dokter Muda Sore kak Perkenalkan nama saya dokter muda Azrul dan ini teman saya CP Bisa kami bertanya ke Bulan? Lagi ngapain tadinya? Udah makan? Sore doc Nama saya Bulan.Pd tapi berhenti sampai semester 4. dihantar sama Discriminatif insignt is good Discriminatif judgement is good No hallusination sekolah sampai kelas berapa bulan? Saya kuliah ambil S. lagi di rumah sakit Udah hampir 1 bulan . makan malam Pasien Interpretation Cooperatif Tau Bulan dimana sekarang? Udah berapa lama disini? Tau. Delusion Tinggalnya sama siapa bulan? Tinggal sama keluarga bang.