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A female patient aged years, came to Psychiatric Polyclinic Prof HB Saanin in Padang
on 13 April 2016 at 17:00 pm, with complaint would like to check the healthy of . Patient have
been control regularly to Psychiatric Polyclinic Dr.M.Djamil Hospital since 2009. Present
complaints still felt by patient are feeling sad, easily exhausted, pessimistic view of the future,
decreased self esteem. She sleep 8 hours per days and eat 3 times per days with one portion
of each. Patients experiencing this since 8 years ago when her husband were married with
another woman.
th
Patient identity:
Name / Age
MR
Gender
Female
Marital status
Married
Religion
Muslim
Occupation / School
Citizen
Indonesian
Tribe
Minangkabau
Address
A. Internal Status
General appearance
Blood pressure
Pulse
Respiration
Temperature
Body Shape
Height
Weight
Cardiovascular system
: Composmentis
: 120/70 mmHg
: palpable, regular, 83 times per minute,
: toracoabdominal, regular, 18 times per minute
: 36,50C
: astenicus
: 160 cm
: 75 kg
: were not examined
Sensibility
Vegetative Function
Basic Function
: Eutonus
: Good
: Good
: Good
555 555
555 555
: Physiologic : Patella Reflex (+/+)
Pathologic : Babinski Reflex (-/-)
: No abnormality detected
: Good appetite, sleep well
: Reading, writing, drawing, and calculating is well done.
Specific disorder
- Rigid
- Oculogyric crisis
- Tremor
- Torticollis
- Nasal stiffness
- Others
: None
: None
: None
: None
: None
: None
Reflex
Allo Anamnesis
Name / Age
Gender
: Dodi
: Male
Address
:-
Phone number
:-
Occupation
:-
Education
:-
Relationship
: Son of patient
2
I.
History of illness :
2006 (the month was not remembered)
Her husband was married with another woman but they werent divorced. Itu
keinginan suaminya dan tidak diketahui sebab yang jelas. It was on her husband own
decision and the reason doing this wasnt be explained by him. In this time, patient started
complaints feeling sad, lost her interest, sleep dificulty and woke up in the middle of night
frequently, felt dissapointed, frequent crying.
She came to Psychiatric Policlinic Dr. M. Djamil Hospital to add drugs prescription.
From interview with the patient, she told about her son plan entering the college or The
Police Academy. She afraid about her financial for her son to continue his study. Present
complaints still felt by patient are feeling sad, easily exhausted, pessimistic view of the
future, decreased self esteem.
Premorbid history
Infant
: born spontaneously, birth was assisted by dukun beranak, no history of
jaundice, cyanosis, and seizure.
Childhood
: growth and development according to his age. She likes to play with friends.
Teenage
: growth and development according to his age. She likes to play with friends.
Adolescence : self-employed, still had a good relationship with the others.
Educational background
SD
: SD N Sungai Limau, not graduated (until 5th grade)
II.
Occupation History
Self-employed
III.
Marital History
Married
IV.
source is from PDAM. Monthly income of the family is more than enough for the patient.
Income
Patients salary
Rp. 0
Outcome
Family cost
Rp. 2.500.000,-
Water cost
Rp.
70.000,-
Electricity cost
Rp.
100.000,-+
V.
Family history of illness
There were no family members that has same symptoms like this or has mental disorder.
Graphic of illness
Her husband married with
anothe woman
2006
2009
2010
2014
Answers
Interpretatio
n
Assalamualaikum
bu Waalaikum salam
Yurnalis
Buk, ambo Nia, dokter muda Buliah...
Composmentis
Cooperative
1964
1 Januari 1964
Di Padang, RSJ Prof HB
saanin
Selasa
Rami-rami duo oto
Good time
orientation
Good personal
orientation
Not good
place
orientation
rumah mintuo
Sejak bilo ibuk suko pakai Iyo suko se.
asesoris tu ?
Suko ibuk pakai warna baju Iyo ancak
Manik
Manik
Waham
katonyo ?
kebesaran
kamari?
Ibuk dari
langik
tadi ?
malam-malam
Kini baa perasaan ibu? Apo Ndak ado taraso apo-apo do.
yang taraso kini bu?
Yang lain apo nan ibuk Iyo, itu se nyo
rasoan?
Kalau
itu,
mandanga
ado
buk?padohal
ndak
urangnyo buk?
Ooo...kalau
Halusinasi
ado
auditorik (+)
Acok
nampak
di
walikota Bukittinggi
bau-bauan?bau Ndak ado doh
Halusination
Berdebar-
Halusinasi
olfaktorik (-)
No anxiety
No Anxiety
debar?
Ado ibuk maraso sadiah Ndak ado do
akhir-akhir ko ?
Ado ibuk maraso bersalah ? Ndak ado do
Ado ibuk bapikia kalau Ndak ado do
No depression
:
:
:
:
:
:
:
:
composmentis/good
cooperative
active
rich
speak clearly
could be done / proper enough / long enough
good enough
good enough
2. Specific condition
A. Affective
1. Affective condition
2. Emotional :
a. Stability
b. Control
c. Echt/unecht
d. Einfuhlung
e. Deep/shallow
f. Differentiation scale
g. Emotional flow
General knowledge
Intelligence prediction
Discriminative insight
Discriminative judgment
Intellectual decreasing
eutim
:
:
:
:
:
:
:
stable
good
echt
adequate
deep
wide
fast
:
:
:
good enough
good enough
personal, and place orientations are good.
:
:
:
:
:
3. Thought condition
a. Central pattern
b. Phobia
c. Obsession
d. Suspicion
e. Delusion
f. Confabulation
g. Dominance, animosity
h. Inferior feeling
i. Much / little
j. Guilty feeling
k. Hypochondria
l. Others
fast
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
none
none
none
none
none
none
none
present
much
none
none
none
none
behavior,
thought,
feeling
are
not
disturbed
II.
No diagnosis
III.
No diagnosis
IV.
Her husband married again for the first time on 2006 and for the second time on
2010
She is afraid not be able to pay for her son study
V.
GAF 80 71
DIFFERENTIAL DIAGNOSIS
I.
II.
III.
THERAPY
Tilsan 1 x 25 mg
Valdimex 1 x 0,5
Haloperidol 1 x 1,5 mg
Anxibloc 2 x 1
PROGNOSIS
11
Onset
Diagnosis
Point
Adult
Mild
Family Support
Marital status
Economic
Medicine
Precipitating factor
Genetic
Others disease
episode
good enough
Married
Lower Middle class
Regularly
Clear
None
None
Clinical
dubia at bonam
Functional
dubia at bonam
Social
dubia at bonam
Good
Depressive
Not good
12