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By
: Trisno Susilo
Wiwi Hermy Putri
Preceptor
P1533
P1544
DEPARTMENT OF PSYCHIATRI
MEDICAL FACULTY OF ANDALAS UNIVERSITY
GENERAL HOSPITAL OF M.DJAMIL PSYCHIATRI HOSPITAL HB
SAANIN
PADANG
2015
I.
IDENTITY OF PATIENT
Name
: Ms. ZY
Sex
: female
Age
: 16 years old
Religion
: Moslem
Ethnic
: Minangkabau
Last education
: Elementary school
Job
: no job
Marriage
: single
Address
: Lubuk Alung
Handphone number
:-
HISTORY OF PSYCHIATRI
Data was get by:
- Autoanamnesis on February 23th, 2015.
- Alloanamnesis to:
Mother (Jusnita) on February 23th, 2015
- Medical record.
A. Main Complain
Can not speak fluently since childhood
B. Recent History
- Initially, patient is difficult to communication since childhood,
slow responding, she seems does not understand the contents of
conversation. She should be asked clearly so she can follow the
orders. When talking she looks scared and confused.
- Patient only play with her cousins at home.
- Patient could help her mother to do daily activity such as cooking,
sweeping and washing.
- Eating and sleeping enough.
- Patient failed to the next grade two times in elementary school. She
only went to school until 5th grade.
- Patient can only mention the word mama, papa at the age of 6
years.
C. Previous History
1. Psychiatry disorder history
- Patient has no psychiatry disorder history.
2. Medical disorder history
1
patient
Explanation :
: Man
: Woman
: living with patient
Internal Status
General Condition
Awareness
Blood pressure
Pulse
regular,
strong
lift,
Respiration
times/minute
:
torachoabdominal,
frequency
frequency
83
21
times/minute
Temperature
: Afebril
Height
: 150 cm
Weight
: 50 kg
Nutritional status
: well
Cardiovascular system
:
Inspection : Ictus cordis not visible
Palpation
Neurologic Status
GCS
: E4M6V5
Meningeal Sign
: absent
Extrapiramidal sign
-
Hand tremor
: absent
Akatisia
: absent
Bradikinesia
: absent
Way of stepping: normal
Balance
: non disturbed
3
V.
Rigiditas
Motoric
Sensorik
Refleks
: absent
:
freely in any direction
555
555propioseptif and exteroseptif
: well
555
555
: Phisiologic
reflex (+), phatologic reflex (-)
Mental Status
Autoanamnesa
Pertanyaan
Jawaban
Siang dek. Ambo dokter Iyo
Interpretasi
Compos mentis
Zahara
Lubuak Aluang
Ibu menjawab
lambek
mangecek
buk,kadang ngarati
kecek
awak,
pandai
mangecek umua 6
Bara umuanyo kini buk?
tahun
16
(diam)
(diam)
(diam)
Iyo
Dirumah sakik
(diam)
jantuang berdebar-debar?
Ba a Zahra, ado raso takuik
(diam)
ka
urang?
insyaallah
kami
ka
disturbe
Discriminative insight
good
Discriminative judgment
good
Spatial orientation intact
disiko
manolong
Ngarati Zahra?
(Menggeleng)
Biasonyo dirumah Zahra Nolong
ibu,
Abulia (-)
manga?
mambarasiahan
rumah, mamasak.
(diam)
(diam)
be evaluated)
Tactil halutination (cannot
bayangan?
Kalau raso diraba-raba atau
dipegang?
Ado membau-bau sesuatu (diam)
be evaluated)
Olfactory halutination
(cannot be evaluated)
dari ma asalnyo?
ado maraso dandam atau (diam)
Animosity/revenge (canot
be evaluated)
Inferior feeling (canot be
baguno?
Makasih yo, beko diperikso yo
evaluated)
samo dokternyo yo
Makasih y buk
: Composmentis
Attention
: less
Attitude
: Cooperative
Inisiative
: less
Motoric behaviour
: hypoactive
Facial expression
: poor
Physical contact
: a. Stability
: stabile
b. Control
: controlled
c. ech unecht
: echt
d. einfuhlung ( invoelaarhaid )
: adequate
5
e. deep-shallow
: shallow
f. differentiation scale
: wide
g. emotion flow
: slow
B. Intelectual Function
a. Memory (amnesia)
b. Concentration
: inadequate
c. Orientation
( time, spatial, personal, situation)
d. general knowledge
e. discriminative insight
: good
g. discriminative judgment
: good
h. intelectual deterioration
: absent
- visual
- olfatorik
- tactil
D. Way of Thingking
1. Psikomobilitas
: slow
2. Thingking process
a. clear and sharp
b. Sirkumstansial
a. Inkoherrent
b. Sperrung
c. Hemmung
d. Flight of ideas
3. Contents
a. Central pattern
b. Phobia
c. Obsess
d. Dellusion
e. Suspicion
f. Confabulation
g. Animosity/revenge
h. Inferior feeling
i. Much/less
: less
j. Guilty feeling
k. Hippochondria
l. Others
: 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
G. Relation to reality
General condition: cooperative, passive, speaking less and not clearly, psychic
contact can be done for short duration of time, attention less.
Specific condition
flow
Intellectual condition : memorizing abililty can not evaluate, concentrarion
inadequate, orientation can not be evaluated, general knowledge can not be
evaluated, discriminative insight good, allegged level of intelegency can
not evaluated, discriminative judgment good, intellectual deterioration
absent
Sensation and perception disorder: illusion and hallucination can not
evaluated.
Process of Thinking: slow, not clear and not sharp, circumstancial can not
evaluated, incoherrent can not evaluated, Sperrung can not evaluated,
Hemmung can not evaluated, flight of ideas can not evaluated,
verbigeration can not evaluated, central pattern can not evaluated, phobia
can not evaluated, delusion can not evaluated, suspicion can not evaluated,
confabulation can not evaluated, animosity and revenge can not evaluated,
inferior feeling can not evaluated, content less, guilty feeling can not
Piracetam 2 x 400mg
Ginkoforce 2x1 tab
Vitamin B1 2 x 10 mg
Vitamin C 2 x 1 tab
B. Psychotherapy :
1.
Patient
Supportif psycotherapy
Psychoeducation
2. Family : Psychoeducation about
Patient disorder
Teraphy
PROGNOSIS
Quo ad vitam
: dubia ad
Quo ad fungsionam : dubia ad
Quo ad sanactionam : dubia ad
XII. CASE ANALYSES
The diagnosys of the patient got from history and physical
examination. Patients main complains is can not speak fluently since
childhood. Physical examination shows normal blood pressure of 120/80
9
10
On 2000, the
patients father died.
Patient more often
dreamy, moody, and
suddenly cried own.
Patient locked
himself in the room.
Patient are not taken
for treatment by his
family.
On 2009, his
mother was died.
On 2003, the
patient suddenly
left the house and
went without a
clear purpose. He
left his wife. He
more often dreamy,
moody, and
suddenly cried.
On 2014, he
rampage and
angry because of
his desire to
marry again not
release. He was
taken to RSUP
M. Djamil and
treated for 25
days.