Case Report Session

Wednesday/ January 21th, 2015

Document of Psychiatric

By

: Muhammad Nadirsyah
Fajar Pradhana

Preceptor

P1562
RP1288

: dr. Yaslinda Yaunin, Sp.KJ

DEPARTMENT OF PSYCHIATRI
MEDICAL FACULTY OF ANDALAS UNIVERSITY
GENERAL HOSPITAL OF M.DJAMIL PSYCHIATRI HOSPITAL HB SAANIN
PADANG
2015
0

I.

IDENTITY OF PATIENT

Name

: Mr. IR

Sex

: man

Age

: 22 years old

Religion

: Moslem

Ethnic

: Minangkabau

Last education

: graduated of Junior high school

Job

: Student

Marriage

:-

Address

: Kampung Lalang, Ampang Kuranji, Padang

Handphone number

: 08526380****

Patient entered the hospital on January 20th, 2015, accompanied by his mother and his
brother
II.

HISTORY OF PSYCHIATRI

Data was get by:

-

Autoanamnesis on January 20th, 2015.

Alloanamneis to:
1. Mother (Ms. Yusnida, 50 years old, a teacher, bachelor of teaching, she live
with patient) on January 20th, 2015
2. Brother (Heru, 18 years old, Senior high school student, he live with patient)
on January 20th, 2015

Medical record.

A. Chief Complain
The patient restless, talked alone, laughed alone, walked alone without direction.

B. Recent History
-

The patient has changed his behaviour become restless, more talked alone,
laughed alone, walked alone without direction since a month before admission.

A month before admission, patient always got insomnia. patient didnt come to
school for examination. He sat alone in road. Few days later, his mother was
called by his teacher.Then, his mother took the patient to the general hospital M.
Djamil, Padang.

Parent was divorce on 2006. And now patient lives with his mother, brothers, and
sister at home. Previously,the patient like be alone behind the house.

C. Previous History
1. Psychiatry disorder history
Patient has no hit history and to injur himself.
On 2014, the patient had psychiatry disorder like talked alone, walked alone
without direction, and like be alone behind the house
2. Medical disorder history
The patient didnt have some medical history disease, surgery history,
accident history, neurologic disorder, tumor, consciousness disorder, HIV.
3. Alcohol and addictive substance using history
There is no history of using nicotine, alcohol, morphine, etc.
D. Private History
1. Prenatal/ Perinatal period
Patient was born as the 7th child of 11 siblings. In the pregnancy, patients
mother had no disease and no consume of medicine. Patient was born on time
2

and norm weight. The pregnancy was helped by indigenous medical

practitioner and cried.
2. Early pediatric period (0-3 years)
Patient grew and developed healthy like others.
3. Middle pediatric period (3-11 years)
Patient grew and developed healthy like others, had friends.
4. Late pediatric period and adolescence period
Patient grew and developed healthy like others, had friends.
5. Adult period
a. Education history
The patient got education until 3nd grade of senior high school.
b. Job history
The patient is student.
c. Marriage history
The patient doesnt marry yet
d. Religion history
The patient is Muslim. She believes to god and prays 5 times a day. She
read Quran. There is no conflict to other faith.
e. Psychosexual history
There is no history of psychosexual history.
f. Social activity
The patient had conflict with his friend at school.
g. Violation of law history
There is no history of violation of law.
E. Family History

Explanation :

: Man
: Woman
: Patient
: living with patient

F. Recent life situation

The patient lives with his mother, brothers, and sister in the house. Their
communication is good. Patient lives in an house,. There is vehicle, there is
electricity, and the water is from PDAM. The salary got from his mother as
teacher.. The salary is enough for her daily needs.
G. Familys perception and hope
Family wanted the patient get well soon and continue his school.
H. Patients perception and hope
The patient doesnt want anything

III.

Internal Status

General Condition

: Moderate ill

Awareness

: Composmentis

Blood pressure

: 120/80 mmHg

Pulse

: regular, strong lift, frequency 85 times/minute

Respiration

: moderate, torachoabdominal, frequency 20 times/minute

Temperature

: Afebril

Height

: 165 cm
4

Weight

: 58 kg

Nutritional status

: well

Cardiovascular system : Inspection : Ictus cordis not visible

Palpation

: Ictus palpable around one finger medial to left

midclavicular line, 5th intercostal space

Percussion : Up: 2nd intercostal space, left: one finger medial

to left midclavicular line, right: dextra sternalis
line
Auscultation:normal and regular heart sound, murmurs absent
Respiratoric System

: Inspection : Simetric statically and dinamically

Palpation

: Fremitus similar between left and right chest

Percusion : Sonor all over the thorax

Auscultation: Vesicular breath sound present, ronchi absent,
wheezing absent
Specific abnormalities : IV.

Neurologic Status

GCS

: E4M6V5

Meningeal Sign

Extrapiramidal sign
-

Hand tremor
: absent
Akatisia
: absent
Bradikinesia
: absent
Way of stepping: normal
Balance
: non disturbed
Rigiditas
: absent

Motoric

Sensorik

: well propioseptif and exteroseptif

Refleks

: Phisiologic reflex (+), phatologic reflex (-)

V.

555 555
555 555

freely in any direction

Mental Status
5

Autoanamnesa
Pertanyaan
Jawaban
Siang diak. Saya dokter Iyo

Interpretasi
Compos mentis

muda Fajar dan ini dokter

muda donny. Buliah kami
tanyo tanyo subanta diak?
Sia namo ?
Bara umua kini ilham?

Ilham Ramadhan
25 tahun

Tahun bara lahia ilham?

Tahun 1993
Hari apo memangnyo kini Hari Selasa
ko ilham?
Baa kok

dibaok kamari Ada deh. Awak dibaok

ilham?

sajonyo

Manuruik

ilham

banget?

Manuruik ilham baa?

tau

kini

Time orientation intact

Discriminative insight
disturbed

patuik Mau tau aja mau tau

ndak ilham dibaok kamari

Ilham

Personal orientation intact

Discriminative judgment
disturbed

Ndak tau do
sadang Dirumah sakik M. Jamil

dima?
Jadi apo nan taraso kini Ndak ado sehat sehat se
ilham?
Sabalumnyo,

nyo
ado Ndak ado tu doh

ilham

maraso

dibisiakkan

Spatial orientation intact

Acustic halutination (-)

sesuatu?
Kalau raso diraba-raba atau Ndak ado do

Tactil halutination (-)

dipegang?
Kalau maliek

Visual halutination (-)

bayang- Ndak ado

bayangan?
Ado membau-bau sesuatu Tu Ndak do

Olfactory halutination (-)

yang busuak tapi ndak jaleh

dari ma asalnyo?
ado maraso dandam atau Indak pernah. Ilham ndak
banci ka urang ndak ilham? jaek.
Pernah
maraso
ndak Ndak lah

Animosity/revenge (-)
Inferior feeling (-)

baguno?
6

Kalau abis dari siko nio Nio pulang lai

manga ilham?
Bara

Abulia (-)

urangilham Lai basabaleh

basaudara?
Ok makasih yo ilham

Personal orientation intact

Ok terimakasih kembali

Based on the examination in January, 20th 2015

I. General Condition
a. Awareness

: Composmentis

Attention

: intact

b. Attitude

: Cooperative

Inisiative

: present

c. Motoric behaviour

: active

d. Facial expression

: rich

e. Speech and verbal

: speak fluently and clearly

f. Physical contact

: can be done, natural, and long-time

II. Spesific condition

A. Natural State of Feeling
1. Afective condition : euthym
2. Emotion Living

: a. Stability

: stabile

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)

: well

b. Concentration

: well

c. Orientation
( time, spatial, personal, situation)

: good

d. general knowledge

: good

e. discriminative insight

: disturbed
7

f. alleged level of intelegency

: in normal avarage

g. discriminative judgment

: disturbed

h. intelectual deterioration

: no

C.Perseption and sensation anomaly

a. illution
b.halutination

: absent
- acustic

: absent

- visual

: absent

- olfatorik

: absent

- tactil

: absent

D. Way of Thingking
1. Psikomobilitas

: slow

2. Thingking process
a. clear and sharp

: clear but not sharp

b. Sirkumstansial

: absent

a. Inkoherrent

: absent

b. Sperrung

: absent

c. Hemmung

: present

d. Flight of ideas

: absent

e. Verbigerasi Persevarative ( Persevaratich )

: 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
8

i. Much/less

: less

j. Guilty feeling

: absent

k. Hippochondria
l. Others

: absent
:-

E. Instinctual impulse disorders

a. Abulia

: absent

b. Stupor

: absent

c. Raptus / impulsivitas

: absent

d. excitement state

: absent

e. sexual deviation

: absent

f. Echophraxia

: absent

g. Vagabondage

: present

h. Piromani

: absent

i. Mannerisme

: present

j. Others

:-

F. Overt anxiety

: absent

G. Relation to reality

: undisrupted

VI. Multiaxial Evaluation

Axis I. Clinical Syndrome
Restless, talking alone, laughing alone, walking alone without direction.
General condition: cooperative, active, speaking fluently and clearly, psychic contact can
be done for long duration of time, attention intact.
Specific condition

Natural state of feeling : euthym, stabile, good controlling, echt, inadequate

einfuhlung, shallow, narrow differentiation scale, slow emotion flow

Intellectual condition : memorizing abililty intact, concentrarion ability intact,

orientation intact, discriminative disturbed, discriminative judgment disturbed,
intelligence level normal, intellectual regression absent

Sensation and perception disorder: absent of illusion and hallucination.

Process of Thinking: slow, clear but not sharp, circumstancial absent, incoherrent
absent, Sperrung absent, Hemmung present, flight of ideas absent, verbigeration
absent, phobia absent, delusion absent, suspicion absent, confabulation absent,
animosity and revenge absent, inferior feeling absent, guilty feeling absent,
hypochondria absent.

Instinctual encouragement: abulia absent, stupor absent, raptus absent, excitement

state absent, sexual deviation absent, echophraxia absent,

vagabondage

present, pyromania absent, mannerisme present.

Anxiety: absent

Relation to reality: undisrupted

Axis II. Personality disorder and mental retardation

No diagnosis
Axis III. General Medical Condition
No history of head trauma, malaria, typhoid, and other disease which needs
hospitalization. No history of alcohol and drugs consumption.
Axis IV. Psychosocial and environment
Like be alone, Parent has divorced
Axis V. Global Assessment of Functioning

Moderate symptomp and disabilities

MULTIAXIAL DIAGNOSIS
10

F. 23.9 Acute and transient psychotic disorders (Its not classified)

II

None

III

None

IV

Like be alone, Parent has divorce

GAF 60 - 51

DIFFERENTIAL DIAGNOSIS
1. F. 23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia
2. F. 23.8 Other Acute and transient psychotic disorders
THERAPY
A. Pharmacotherapy :

Olandoz 10mg 1x1 tab (Night)

Hexymer 2mg 1x1 tab
Fluoxetin 10mg 1x1 tab (Morning)

B. Psychotherapy :
1.

Patient
Supportif psycotherapy
Psychoeducation
2. Family : Psychoeducation about
Patient disorder
Teraphy
PROGNOSIS
Quo ad vitam
: bonam
Quo ad fungsionam : dubia ad bonam
Quo ad sanactionam : dubia ad bonam

XII. CASE ANALYSES

The diagnosys of the patient got from history and physical examination. Patients
chief complains restless, talked alone, laughed alone, walked alone without direction
11

since one month before admission. Physical examination shows normal blood pressure of
120/80 mmHg. Cardiovascular, respiratory, gastrointestinal, and neurologic examination
shows no abnormalities.
A month before admission, patient didnt come to school for examination. He sat
alone in road. Few days later, his mother was called by his teacher.Then, his mother
took the patient to the general hospital M. Djamil, Padang. Patient lives with his mother,
brothers, and sister at home. Previously,the patient like be alone behind the house. Their
communication is good. Patient lives in an house,. There is vehicle, there is electricity,
and the water is from PDAM. The salary got from his mother as teacher.. The salary is
enough for her daily needs.
On 2014, the patient had psychiatry disorder like talked alone, walked alone without
direction, and like be alone behind the house
Psychic contact can be done, proper, persist for long duration, euthym, stabile, good
controlling, echt, shallow, narrow differentiation scale, slow emotion flow Intellectual
function unimpaired. There are disturbed discriminative insight and judgment also
present of Hemmung in thinking process.
Patient is diagnosed Acute Psichotyc disorder type as stated in the PPDGJ-III.. The
symptoms consist of talked alone, present of vagabondage, mannerisme, and, also
unimpaired perception. These symptoms are not obvious nor diagnostic. Might be the
examination was not perform in early time. So these minimalize or loss diagnostic
symptomps. Triggering event is not clear. less attention from his parent is believed to
play a role in present symptom and also divorce of parent make the condition worse.
Given Prognosis to this patient is good, because the disease is acute and there is
adequate family support. Patient is given Olandoz 10mg 1x1 tab (Night), Hexymer 2mg
1x1 tab, Fluoxetin 10mg 1x1 tab (Morning).

12

SCHEME OF DISEASE HISTORY

Year

: 2014 (August)

Age

: 21 years old

The patient like be

alone behind the
house, and patient
changed his
behaviour become
restless, more talked
alone, and laughed
alone

Year

: 2015

A month before
admission, patient
didnt come to
school for
examination. He sat
alone in road. Few
days later, his
mother was called
by his teacher.