A 40 years old man was admitted to General Centre Hospital Dr. M. Djamil Padang Polyclinic on July 16 th, 2014 at 10. P.m.with his family. This patient feeling was sick because he can see something that another people can't see, feeling alone and think every people is lier. This is his first visit to psychiatry polyclinic.
A 40 years old man was admitted to General Centre Hospital Dr. M. Djamil Padang Polyclinic on July 16 th, 2014 at 10. P.m.with his family. This patient feeling was sick because he can see something that another people can't see, feeling alone and think every people is lier. This is his first visit to psychiatry polyclinic.
A 40 years old man was admitted to General Centre Hospital Dr. M. Djamil Padang Polyclinic on July 16 th, 2014 at 10. P.m.with his family. This patient feeling was sick because he can see something that another people can't see, feeling alone and think every people is lier. This is his first visit to psychiatry polyclinic.
Gangguan Afektif Bipolar Episode Kini Manik dengan Gejala Psikotik
OLEH FARHAN NAZIR P.1422 RAHMAT FERYADI P.1428
PEMBIMBING dr. Yaslinda Yaunin, Sp.KJ
BAGIAN PSIKIATRI FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS RSUP DR M DJAMIL PADANG 2014
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Bed Site Teaching A 40 years old man was admitted to General Centre Hospital Dr. M. Djamil Padang Polyclinic on July 16 th , 2014 at 10.30 p.m.with his family. This patient feeling was sick because he can see something that another people cant see, feeling alone and think every people is lier. This is his first visit to psychiatry polyclinic. Patient identity: Name and Age : Ny. NLN/ 24 years old MR : Gender : Female Place and date of birth : Marital status : Married Address : Occupation/School : Jobless / graduated from Vocation High School Religion : Islam Citizen : Indonesian Tribe : Minangnese
A. Internal Status General appearance : Compos Mentis Blood pressure : 110/80 mmHg Pulse : easily palpable, regular, 84 x per minute Respiration : abdominothoracal pattern, regular, 20x per minute Temperature : 36,8 0 C Height : Weight : Cardiovascular system : No abnormality detected Digestive system : No abnormality detected Specific disorder : No abnormality detected
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B. Neurological Status Cranial Nervous (five senses) : Vision, smelling, hearing, tasting, and tactil are well Meningeal Signs : None High Intracranial Pressure Signs : None Eyes - Movement : Free to all direction - Perception : No nystagmus, no diplopia - Pupil : Round and isokor - Light Reflex : +/+ - Convergence Reaction : Not examined - Ophtalmoscopic examination : Not examined Motoric - Tonus : Eutonus - Turgor : Good - Strength : Good - Coordination : Good - Reflex : Physiologic (+/+), pathologic (-/-) Sensibility : No abnormality detected Vegetative Function : Good appetite, sleep well Basic Function : No abnormality detected Specific disorder - Rigid : None - Tremor : None - Nasal Stiffness : None - Oculogyric Crisis : None - Torticolis : None - Others : None
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Allo-history taking: July 23 th 2014
a. Name and age : b. Address : Alai Barat Street, No. 25, Parak Kopi, North Padang c. Phone Number : 085272221553 d. Occupation : Housewife e. Education : Junior High School f. Relationship : Wife
Primary cause of hospitalization The patient was admitted to M. Djamil Hospital because prick her mother, threw glass and plate at home
History Illness 2011 : Patient was firstly married after graduated from high school. After maried they lived in Duri. Problem came when her husband not care anymore, he is busy with his job and come home rarely. Since then, patient always sad, like to be alone and iritable. Her husband took her home in Suliki. At her parents home she start act bizzare like naked inside the house, talking with nobody, laughing by herself, pulling her hair and so on. Her parents took her to the paranormal, after the medication she feel helathy and could do normal activity. She came back live with her husband in Duri for 4 months but next 2 months she act bizzare like the old day because she is jealous with a woman who close with her husband. She came back home to her parents home and their parents took her to the psychiatrist in Bukittinggi and got prescription but she is not obey to took the medicine. Patient went to Puskesmas and given 3 drugs. After consuming the drugs the patients getting better and act like normal people. She could talk to others and could do the activity well. When the drugs is run out, she went to midwive to get the drugs, but the midwives change the drugs after that there are so many blister on her whole body, her lips exfoliate and became darker. Since then she stopped consuming the drugs. She start acts bizzare like the old day before she took medication like iritable, talking alone, laughing by herself. 5
2014 : On the early January, patient got a job at a shop as a servant. In that shop, she open her ex husband profile facebook. Since then she became sad, agitation, walking outside the house without destination. She dont want eat and sleep. She talking alone and laughing alone, prick her mother if their wants not realised. She like play with fire and burn something thet interest her such as paper. She like sharp tools such as knife but didnt harm other people.
Premorbid history Infant : born spontaneously, birth was assisted by midwife, no history of jaundice, cyanosis, and seizure. Childhood : growth and development according to his age. Adolescence : she is not going to the college because someone proposed her
Educational background Elementary School at SD N 21 Indrapura, not graduate, just reach levl 5 th because patients family havent enough money for school
Social economy history Living with his parents, had a semipermanent house, had a TV and electricity on it, water supply from National Water Company, had no home-phone.
Biological development background Head traumas history was not present, No history of malaria, typhoid, or brain and neurological disease No Alcohol history and addicted drugs
Occupation History Patient work as a servant in a shop a week at January 2014
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Marital History Patients was married two times 2011 : he was married when she was 21. Have no children and divorce in 2013 because his husband dont like her act. 2014 ; he is married for second time when she was 24 years old. She is 7 months old pregnant now. Family history of illness
Note: : patient
: women
: man
: man who had same illness like patient
There was family members that has same symptoms like this which is patients uncle.
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Graphic of illness
Auto-history taking, July 23 th 2013 : Questions Answers Interpretation Assalamualaikum Pak. Saya dokter muda Farhan dan Rahmat, boleh kami ngobrol dengan bapak? Waalaikumsalam, boleh dek. Mau ngobrol apa?
Cooperative
Nama bapak siapa?
Umur bapak berapa?
Saya Pak Khairul Yahya.
Sekarang saya 40 tahun Pak, kalau boleh tahu kenapa bapak bisa sampai di rawat disini? Iya, saya sendiri yang ingin di rawat. Saya meminta keluarga saya untuk membawa saya kemari dek. Saya merasa emosi saya meluap-lupa terus, jadi saya ingin dirawat untuk dapat obat penenag dek. Terus saya juga malas makan semenjak emosi saya ini menjadi- jadi dan saya gak
bisa tidur dek. Oh begitu, memangnya sejak kapan emosi bapak menjadi meluap-luap? jadi ceritanya gini dek, 1 minggu yang lalu ada kawan dekat saya yang diancam sama orang Aceh tetangga teman saya ini. Dia memang lawannya teman saya dek. Jadi saya sebagai temannya merasa marah karena dia diperlakukan seperti itu, mulai saat itu saya rasanya mau berantam saja sama orang tersebut biar saya lega dan emosi saya bias turun dek
Terus pak puncak emosi bapak itu kapan?
Memangnya arti teman buat bapak itu seperti apa? Terutama teman bapak yang satu ini Ya pas sebelum saya masuk dek. Saya melihat teman saya itu dikeroyok dengan orang- orang yang mengancam itu dan saya rasanya mau memukul mereka dek. Jadi saya ambil balok dan golok dek untuk menakut-nakuti mereka. Dia itu teman kecil saya. Sebenarnya saya sudah tidak dekat dengan dia karena dia nakal. Tapi kemaren itu dia mau bertobat makanya saya mau berteman lagi. Makanya
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ketika ada yang ganggu dia saya sangat marah dan emosian. Oh begitu, terus bapak ada mendengar suara-suara ga sebelum ngamuk-ngamuk seperi itu? Kalau melihat sesuatu bayangan? Kalau mencium bau busuk, bau kemenyan? Kalau merasa seperti ada yang memegang dan menyentuh bapak? Gak ada dek
Gak ada juga
Gak ada dek
Gak ada juga dek Halusinasi tidak ada
Ooo jadi bapak memang seringnya emosinya meluap dan suka ngamuk-ngamuk seperti itu? Ya dek saya gk ngerti juga kenapa bias seperti itu
Bapak sebelumnya pernah mengalami hal seperti ini juga? Pernah dek sekitar 6-7 tahun yang lalu
Bapak sampai dirawat karena hal itu? Pernah dek. Saya dirawat di RSJ Gadut kalau gk salah tahun 2008 dek
Kenapa bapak dirawat? Atas keinginan sendiri atau gimana Iya de katas keinginan sendiri, saya merasa butuh penenang
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pak? makanya mau dirawat. Disana saya dirawat selama 3 hari Lalu? Terus saya dipulangkan dengan obat pulang dan disuruh rutin control dek
Berapa lama bapak makan obatnya? Setelah habis obat bapak rutin control? Obatnya habis 6 bulan dek siap itu saya gk control lagi karena merasa sudah tenang dek.
Ooooo. Selain tahun 2008 itu pak, kapan lagi bapak di rawat? Hmm tahun 2009 dek. Di RSJ Gadut juga.
Bapak kesana atas keinginan sendiri lagi? Dirawat berapa lama pak? Ya dek, atas kemauan saya sendiri. Saya disana hanya 3 hari, tapi keluarga saya menjemput saya pas hari ke 17 dek karena keluarga saya takut saya nanti masi sering ngamuk-ngamuk kalau dibawa pulang.
Bapak pulang dikasih obat juga? Di anjurkan control? Iya obatnya untuk 6 bulan jugak dek dan saya gak rutin control juga siap habis obatnya.
Kalau kita boleh tau pak, penyebab bapak ngamuk- ngamuk dan emosian pas dulu Kalau di tahun 2008 saya sudah tidak ingat dek. Tapi yang dirawat tahun 2009 saya
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itu apa ya pak?
di rawat karena masalah kerjaan saya dek, saya merasa dibohongi Bapak pernah ngerasa rendah diri nggak?
Bapak pernah juga gak ketika dulu mengalami kesedihan yang mendalam, rasa tidak berguna, pokoknya yang sedih-sedih gitu pak? Nggak dek. Gk pernah. Sehari-hari saya aktif dek. Saya malah selalu percaya diri dek
Gak pernah dek. Saya happy terus. Cuma saya juga gak tau kenapa terkadang emosi saya meluap-luap Inferior Feeling is absent
Depreesion feeling is absent Hubungan bapak sama keluarga seperti apa? Sampai saat saudara-saudara saya tidak ada yang menjenguk saya. Di tahun 2008 dan 2009 saya sempat di pasung selama 4 hari karena ngamuk-ngamuk makanya saya lebih baik dirawat. Tahun 2014 ini juga saya setelah keroyokan itu sempat di pasung juga dek.
Oooo. Bapak ada cita-cita yang gak kesampaian gak? Dulu ada dek. Saya dulu ingin sekali jadi tentara tapi tidak kesampaian. Sekarang gk ada lagi cita-cita seperti itu Obsession is absent Bapak ada ngerasa curiga gk Saya gak pernah ada curiga Suspicious is absent 12
sama oarng-orang sekitar? Kalau rasa dendam gitu pak? Cemas-cemas pak? sama orang dek Dendam juga gak ada Repulsions is absent Over anxiety is absent Bapak ada merasa bersalah gak pak setelah semua kejadian ini? Iya dek. Ada. Saya merasa bersalah dan saya takut kalau keponakan-kepoakan saya tau akan kejadian ini dan ikut terlibat nantinya dek. Feeling guilty is present Jadi sekarang bapak ngerasa ada sakit gak? Saya merasa emosi saya tidak terkontrol makanya saya mau disini dirawat biar tenang Discriminative insight not disturb Pak, hari ini hari apa? Rabu Time Orientation is good Tanggal? 23 Juli 2014 Time Orientation is good Place Orientation is good
Personal Orientation is good Ini dimana sekarang? Di rumah sakit M Jamil dek Tau Presiden sekarang siapa? Presiden yang baru menang pak? SBY Jokowi dek Bapak suka pergi jalan-jalan sendiri? Ngak tentu arah. Ndak sadar dimana Nggak ada dek
Vagabondage is absent Bapak suka mambakar-bakar sesuatu gitu gak? Nggak kok. Pyromani is absent Pak ada merasa takut-takut gitu gak? Gak dek, saya gak ada takut sama apapun dek Phobia is absent 13
O iyo pak. Coba tolong Buat gambar agak satu. Trus menulis disini Oh jadih Ini dek uda siap
Bapak masih ingat nama saya dan kawan saya? Masih. Dokter farhan sama rahmat Memory is good Oke pak, makasih banyak ya Iyo sama-sama dek
EXPLANATION AND CONCLUSION OF PSYCHIATRIC EXAMINATION Examination is on July 23 th 2014, 01.45 p.m WIB 1. General appearance Consciousness/sensorial : compos mentis/good Attitude : cooperative Motoric : active Facial expression : Verbalization : speak not clearly and not fully understood Physic contact : couldnt be done / inappropriate / a while Attention : not good Initiative : none Specific condition A. Affective 1. Affective condition : hypotim 2. Emotional : a. Stability : instable b. Control : not good c. Echt/unecht : unecht d. Einfuhlung : inadequat e. Deep/shallow : shallow 14
f. Differentiation scale : narrow g. Emotional flow : slow
B. Intellectual condition of function a. Memory : not good b. Concentration : not good c. Orientation : not good d. General and schooling knowledge : couldnt e. Discriminative insight : disturbed f. Intelligence prediction : average g. Discriminative judgment : disturbed h. Intelectual deterioration : none
C. Sensation and perception abnormalities 1. Illusion : none 2. Hallucination : Acoustic : exist Visual : exist Olfactory : exist Tactile : none D. Thought process condition 1. Speed of thought processs : slow 2. Quality of thought process: a. Clear and sharp : not clear and not sharp b. Circumstantial : none c. Incoherent : exist d. Sperrung : none e. Hemmung : none f. Flight of ideas : none g. Verbigeration : none 15
h. Preservation : none
3. Thought condition a. Central pattern : none b. Phobia : none c. Obsession : none d. Delusion : none e. Suspicion : none f. Confabulation : none g. Repulsion : none h. Inferior feeling : none i. Much/little : much j. Feeling guilty : present k. Hypochondria : none l. Others : none
E. Instinctual drive and behavior abnormalities a. Abulia : exist b. Stupor : none c. Raptus/impulsivity : exist d. Excitement state : none e. Sexual deviation : none f. Echopraxia : none g. Vagabondage : none h. Pyromania : none i. Mannerism : none j. Others : none
F. Over anxiety : none G. Reality testing ability : not disturb in attitude, thought, feeling 16
MULTIPLE AXIS RESUME Axis I. Clinical Syndrome The patient Phsyciatric examination: General Appeareance: compos mentis, cooperative, active, poor facial expresion, couldnt speak clearly, psychic contact could be done, inappropriate and a while. Specific condition: a. Affective condition: hypertim, stable, good enough, echt, inadequate, deep, narrow, fast. b. Intellectual condition and function: good memory, concentration good enough, good orientation, schooling and general knowledge good enough, intellectual deterioration not disturb, discriminative insight and judgement not disturb. c. Sensation and perception abnormalities: no illusion, acoustic, visual, tactil and olfactoric hallucination present since childhood. d. Thought process condition: fast, clear and sharp enough, much. e. Instinctual drive and behavior abnormalities: none f. Overt anxiety: none g. Reality testing ability, not disturb in attitude, thought, feeling 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 not present 17
No history of malaria, typhoid, or brain and neurological disease No history consuming alcohol and other addictive drugs Axis IV : Phsychosocial Stressor and Environment: Not consuming drugs anymore Axis V: Global Assessment of Function Social relationship couldnt be done Occupatinal couldnt be done Spending time with watching TV, travelling, could be done MULTIPLE AXIS DIAGNOSIS I. F.31.2 Bipolar Affective Disorder Manic Episode with Psychotic Symptoms II. No Diagnosis. III. No Diagnosis IV. No Diagnosis V. GAF 90-81. DIFFERENTIAL DIAGNOSIS I. F 25.0 Manic type schizoaffective II. F 31.8 Others Bipolar Affective Disorder