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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 MR Gender Place and date of birth Marital status Address Occupation/School Religion Citizen Tribe Name/Age Address Occupation Relationship with patient A. Internal Status General appearance Blood pressure Pulse Respiration Temperature Body Shape : Compos Mentis : 110/70 mmHg : easily palpable, regular, 74x per minute, : abdominotorakal pattern, regular, 17x per minute : 36,80C : astenikus
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: : : : : : : : : :

Etmayeni / 28 years old 66976 Female Pesisir Selatan, July 1st 1983 Married Tanjung Merdeka, Indrapura Utara Pesisir Selatan No Occupation/Senior High School Indrapura Muslim Indonesian Minangnese

Allo-anamnesis was given by: : Sawir / 38 years old : Tunggul Hitam (075131422) : Enterpreneur : Cousin

Height Weight

: 150 cm : 43 kg

Cardiovascular system : No abnormality detected Digestive system Specific disorder : No abnormality detected : No abnormality detected

B. Neurological Status Cranial Nervous (five senses) Meningeal Signs : Vision, smelling, hearing, tasting, and tactil are well : None

High Intracranial Pressure Signs : None Eyes Movement Perception Pupil Light Reflex : Free to all direction : No nystagmus, no diplopia : Round and isokor : +/+ : Not examined

Convergence Reaction

Ophtalmoscopic examination : Not examined

Motoric Tonus Turgor Strength : Eutonus, tremor (+/+) : Good : Good


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Coordination Reflex

: Good : Physiologic (+/+), pathologic (-/-) : No abnormality detected : Good appetite, sleep well : No abnormality detected

Sensibility Vegetative Function Basic Function Specific disorder Rigid Tremor Nasal Stiffness

: None : +/+ : None

Oculogyric Crisis : None Torticolis Others : None : None

Laboratorium (September, 30th 2011) Hemoglobin Leukocyte Thrombocyte Diff Count : 11,5 g/dl : 7400/mm3 : 250.000/mm3 : 0/0/1/73/22/4

Autoanamnesis, November 20th 2011 : Questions Answers Interpretation


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Assalamualaikum ni,, Uni siapa namanyo? Panggilan ibu sia? Baa kaba ibu kini? Lai lamak makan? Siang ko alah makan tadi? Lai lamak lalok ni? Lah bara lamo uni disiko?

Waalaikumsalam Etmayeni Et sehat Lai alah lai Lah lamo cooperative

Samo sia uni dulu dibawa Jo amak, keluarga kasiko? Oh iyo uni, baa caritonyo Mmm,,,(pasien senyum) sampai uni dirawat disiko, caritoan la ka kami,, Baa uni lai wajar uni dirawat Bilo awak pulang buk??? di siko? Ee alun buliah lai tanyo ka Yo buk dokternya besok yo Lai tau dima iyet kini? Bara urang iyet badunsanak? Di rumah sakit 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? Dima suami kini? alah Di kampuang
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Anak alah ado? Dimanyo kini? Samo sianyo? Lai tarakak iyet jo inyo

Alah,, Di rumah Jo ibu lai

Kalo lah pulang bisuak ko jan Ndak buk,,(senyum) marabou-rabo juo ka ibu jo anak ndak Dulu tu ado masalah iyet Ndak ado do buk sampai marabou ka ibu jo anak? Tu baa ko marabo se? Ada yang Hmmm,,

menyuruh ndak

/membisikkan ka talingo ga? Ado Nampak bayangan ga lai yet? Siapo tu? Ado yang dikecekkannyo ka iyet? Waktu itu lai di pegangnyo ga lai iyet? Lai pandai iyet manggambar, Ee,,ndak bisa do buukk buek gambar di karate ko yo,,suret jadih juo,, Ayolahh Yet,, 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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Wajah kakak lai

kamar karena malu) Makasih yaa niii,,,,

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.

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 Adolescence : : growth and development according to his age. 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

Drug Withdrawalalcoholic historydap ekonomi keluagaya, lalu lari ke kamar karena malu There were no family members that has same symptoms like this.

Graphic of illness

EXPLANATION AND CONCLUSION OF PSYCHIATRIC EXAMINATION Examination is on November 19th 2011, 1 p.m WIB 1. General appearance Consciousness/sensorial Attitude Motoric Facial expression Verbalization Physic contact Attention Initiative 2. Specific condition A. Affective 1. Affective condition 2. Emotional : a. Stability b. Control : : unstable not good enough
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: : : : : : : :

compos mentis/good cooperative active in appropriate speak clearly could be done / inappropriate / long enough not good enough not good enough

flat

c. Echt/unecht d. Einfuhlung e. Deep/shallow f. Differentiation scale g. Emotional flow

: : : : :

echt inadequat shallow narrow fast

B. Intellectual condition of function a. Memory b. Concentration c. Orientation : : : not good enough not good enough good can not predicted

d. General and schooling knowledge : e. Discriminative insight f. Intelligence prediction g. Discriminative judgment h. Intelectual deterioration : : : :

disturbed average disturbed none

C. Sensation and perception abnormalities 1. Illusion 2. Hallucination Acoustic Visual : none : : present, since 3 month ago lost in last 7 days : present, since 3 month ago lost in last 7 days
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Olfactory Tactile Gustatory

: none : none : none

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

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

: : : : : : : :

none none none none much none none none

E. Instinctual drive and behavior abnormalities a. Abulia b. Stupor c. Raptus/impulsivity d. Excitement state : : : : present none none present, since 3 month ago, decrease in the last 1 and half months e. Sexual deviation f. Echopraxia g. Vagabondage h. Pyromania i. Mannerism j. Others : : : : : : none none none none none none
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F. Over anxiety G. Reality testing ability

: :

none 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. II. F.31.2 Bipolar Affective Disorder Manic Episode with Psychotic Symptoms No Diagnosis.
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III. IV. V.

No Diagnosis

GAF 41-50.

DIFFERENTIAL DIAGNOSIS I. II. F 31.6 Bipolar Affective Disorder Mixed Episode F 25.0 Manic type schizoaffective

THERAPY Risperidon 2 x 1 mg Haloperidol 2 x 5 mg THP 2 x 2 mg

PROGNOSIS Clinical Functional Social : : : dubia at malam dubia at malam dubia at malam

SUGGESTION FOR THERAPY Education to the family

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