bst buk linda, lia widya

7/27/2019 BST Buk Linda, Lia Widya

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Case Presentation

A 23 years old man was admitted to HB Sa’anin Padang emergency unit on June 26th 2013, and

escorted by his family. This patient was admitted with nude while running around his home,

bother other people, rolling on the heap of rice, always playing toys with a child, feel like a God,

talked a lot but incoherent, smiling and laughing alone, restlessness, almost never slept at night,

angry for no reason, since two days before hospitalized . Sick for the second time and

hospitalized for the first time. The sickness is worse than before.

Patient identity:

Name and Age : Herzi Razab Putra / 23 years old

MR : not identified

Gender : Male

Place and date of birth : Simpang Empat, February 11th 1990

Marital status : Single

Address : Plasma Tiga Klp 54 Jorong Bukit Nilam Aur Kuning, Pasaman

Barat

Occupation/School : No Occupation/Senior High School

Religion : Islam

Citizen : Indonesian

Tribe : Mandailing

A. Internal Status

General appearance : Compos Mentis

Blood pressure : 110/80 mmHg

Pulse : easily palpable, regular, 81x per minute,

Respiration : abdominotorakal pattern, regular, 21x per minute

Temperature : 36,90C

Body Shape : astenikus

Height : 170 cm

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Weight : 68 kg

Cardiovascular system : No abnormality detected

Digestive system : No abnormality detected

Specific disorder : No abnormality detected

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, tremor (+/+)

- Turgor : Good

- Strength : Good

- Coordination : Good

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- Reflex : Physiologic (+/+), pathologic (-/-)

Sensibility : No abnormality detected

Vegetative Function : Good appetite, sleep well

Basic Function : No abnormality detected

Specific disorder

- Rigid : None

- Tremor : +/+

- Nasal Stiffness : None

- Oculogyric Crisis : None

- Torticolis : None

- Others : None

Autoanamnesis, July 1th 2013 :

Questions Answers Interpretation

Herzi, kenalkan ini Lia, ini

widya, boleh kami tanya-tanya

Herzi sebentar?

Iya nggak apa apa, tanya lah Cooperative

Berapa umur Herzi? 23 tahun, tanggal 11 Februari

lahir.

Memorize is good

Udah berapa hari Herzi disini? Dari hari Kamis. Time orientation is good

Apa yang terasa sekarang

Herzi?

Nggak ada, Cuma lemas aja

sedikit.

Makan mau nggak? Habis? Mau, habis

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Tidurnya gimana? Tidurnya mulai jam 8

Herzi tahu dimana sekarang? Tau, di rumah sakit jiwa Place orientation is good

Kenapa Herzi di bawa kemari? Nggak tau Discriminative insight is

disorder Menurut herzi, wajar nggak

Herzi di rawat disini?

Nggak, saya nggak sakit jiwa

Sama siapa Herzi kesini?

Pakai apa?

Keluarga yang antar, pakai

mobil merah, di carter punya

orang.Person orientation is good

Waktu dibawa kesini, Herzi di

ikat atau nggak?

Nggak ada di ikat, tapi di

pasung, sebelum masuk

kesini.

Situation orientation is good

Ada Herzi nampak bayang-

bayang pas masuk kesini?

Nggak ada. Visual, akustik and olfactoric

hallucination aren’t present

Mendengar bunyi-bunyi aneh

atau suara orang

mengomentasi Herzi?

Nggak

Mencium bau bau harum atau

busuk ada nggak?

Nggak

Herzi pernah nggak merasa

menjadi seseorang?

Iya, dulu merasa seperti Allah,

ahaha..

Dellucion is present

Tanggal berapa sekarang

Herzi? Bulan apa? Tahun

berapa?

Tanggal 1 bulan Juli tahun

2013

Time orientation is good

lima hari lagi, tanggal berapa? Tanggal 6

Udah nikah Herzi? Belum

Apa kerja Herzi kalau di

rumah?

Bantu bantu, kalau ada pokat

ambil pokat, kalau ada kayu

ambil kayu.

4



Oh iya, Herzi, ini ada dua

kertas, satu untuk Herzi tulis,

satu lagi untuk bikin gambar,

ini penanya..

Gambar gambar apa? Tulis

tulis apa?

Boleh cerita boleh buat surat,

gambar apa yang ada di

pikiran Herzi aja

(mengangguk) Inisiative is good

Iya lah, makasih ya Herzi,

udah mau kami tanya-tanya.

Istirahat lah lagi.

Iya (menggangguk dan

tersenyum)

Alloanamnesis:

Allo-anamnesis was given by:

Name/Age : Pendra / 38 years old

Address : Plasma Tiga Klp 54 Jorong Bukit Nilam Aur Kuning, Pasaman

Barat (085364092009)

Occupation : Swasta

Relationship with patient : Older Brother

Primary couse of hospitalization

Patient was nude while running around his home, bother other people, rolling on the heap of rice,

always playing toys with a child, feel like a God, talked a lot but incoherent, smiling and

laughing alone, restlessness, almost never slept at night, angry for no reason, since two days

before hospitalized. Sick for the second time and hospitalized for the first time. The sickness isworse than before.

Present complain of patient

There is no complaint at this time.

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History of illness:

2011 (forgot month)

Patient talked a lot but incoherent, smiling and laughing alone, restlessness, almost never

slept at night, but family’s patient brougt to indigenous medical practitioner.

2013 (June)

Patient was nude while running around his home, bother other people, rolling on the heap of

rice, always playing toys with a child, feel like a God, talked a lot but incoherent, smiling

and laughing alone, restlessness, almost never slept at night, angry for no reason, since two

days before hospitalized. Sick for the second time and hospitalized for the first time. The

sickness is worse than before.

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 : had a lot of friends, easy making new friends and outgoing person, but

now because of his condition his friends avoid him

Educational background

Elementary School at SD N Lembah Binuang, Pasaman Barat, graduated in 6 years, top ten

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Junior High School at SMP N Lembah Binuang, Pasaman Barat for 1 years, and then

continued Pesantren Lembah Binuang for 2 years.

Senior High School at MAN Kinali Pasaman Barat, for 1 years. And then continued to MAN

Kapri Pasaman Barat until he graduated.

Social economy history

Living with his parents, had a permanent house, had a TV and electricity on it, water supply

from Municipal Water Corporation, had a motorcycle.

Biological development background

• Trauma’s history was present (8 years ago), but not vomiting and was never hospitalized

after trauma

• No history of malaria, typhoid, or brain and neurological disease

• Consumption drug (dextrometropan once about 30 pils) when he graduated MAN

Family history of illness

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♂ ♀

♂ ♀

♂ ♀ ♀ ♂ ♂

♂ ♀ ♂

♂ ♀ ♀ ♂ ♂ ♂ ♂

♂



There were no family members that has same symptoms like this.

Graphic of illness

EXPLANATION AND CONCLUSION OF PSYCHIATRIC EXAMINATION

Examination is on July 1st 2013, 2 p.m WIB

1. General appearance

Consciousness/sensorial : compos mentis/good

Attitude : cooperative

Motoric : active

Facial expression : rich

Verbalization : speak clearly

Physic contact : could be done / appropriate / long enough

Attention : good

Initiative : good

2. Specific condition

A. Affective

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201 201



1. Affective condition : eutyme

2. Emotional :

a. Stability : stable

b. Control : good enough

c. Echt/unecht : unecht

d. Einfuhlung : inadequat

e. Deep/shallow : shallow

f. Differentiation scale : narrow

g. Emotional flow : fast

B. Intellectual condition of function

a. Memory : good

b. Concentration : good enough

c. Orientation : good

d. General and schooling knowledge : can not predicted

e. Discriminative insight : disturbed

f. Intelligence prediction : average

g. Discriminative judgment : disturbed

h. Intelectual deterioration : none

C. Sensation and perception abnormalities

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1. Illusion : none

2. Hallucination :

Acoustic : none

Visual : none

Olfactory : none

Tactile : none

Gustatory : none

D. Thought process condition

1. Speed of thought processs : fast

2. Quality of thought process:

a. Clear and sharp : clear and sharpless

b. Circumstantial : none

c. Incoherent : none

d. Sperrung : none

e. Hemmung : none

f. Flight of ideas : none

g. Verbigeration : none

h. Preservation : none

3. Thought condition

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a. Central pattern : present

b. Phobia : none

c. Obsession : none

d. Delusion : present

e. Suspicion : none

f. Confabulation : none

g. Repulsion : none

h. Inferior feeling : none

i. Much/little : much

j. Feeling guilty : none

k. Hypochondria : none

l. Others : none

E. Instinctual drive and behavior abnormalities

a. Abulia : none

b. Stupor : none

c. Raptus/impulsivity : none

d. Excitement state : present, since 2 days ago

e. Sexual deviation : none

f. Echopraxia : none

g. Vagabondage : none

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h. Pyromania : none

i. Mannerism : none

j. Others : none

F. Over anxiety : none

G. Reality testing ability : disturb in behavior, feeling and thinking

MULTIPLE AXIS RESUME

Axis I. Clinical Syndrome

Patient was nude while running around his home, bother other people, rolling on the heap of

rice, always playing toys with a child, feel like a God, talked a lot but incoherent, smiling

and laughing alone, restlessness, almost never slept at night, angry for no reason, since two

days before hospitalized. Sick for the second time and hospitalized for the first time. The

sickness is worse than before.

Phsyciatric examination:

General Appeareance: compos mentis, cooperative, active, rich, can speak clearly, psychic

contact could be done, appropriate and long enough.

Specific condition:

a. Affective condition: eutiyme, stable, good enough, unecht, inadequate, shallow, narrow,

fast.

b. Intellectual condition and function: good memory, concentration is good, good

orientation, absent intelectual deterioration, discriminative insight and judgment are

disturbed.

c. Sensation and perception abnormalities: no illusion, no hallucination.

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d. Thought process condition: fast, clear and sharpless, central pattern present, delusion

present, much.

e. Instinctual drive and behavior abnormalities: excitement state is present, since 2 days

ago, decrease since hospitalized.

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 but now because of his condition his friend

avoid him.

Mental retardation: none

Axis III : General Medical Condition

• Trauma’s history was present

• No history of malaria, typhoid, or brain and neurological disease

•Consumption drug (dextrometropan once about 30 pils) when he graduated MAN

Axis IV : Phsychosocial Stressor and Environment

Patients had social problems with his friend

Axis V: Global Assessment of Function

Social relationship couldn’t be done since sick

Spending time with watching TV, travelling, couldn’t be done since sick

MULTIPLE AXIS DIAGNOSIS

I. F.20.1 Schizofrenia Hebefrenic

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II. No Diagnosis.

III. Consumption drug (dextrometropan once about 30 pils) and trauma’s history

IV. Social and environment problem

V. GAF 60-51 (symptom moderate, disability moderate)

DIFFERENTIAL DIAGNOSIS

I. F 31.6 Bipolar Affective Disorder Manic Episode with the psikotic symptom

II. F 25.0 Manic type schizoaffective

THERAPY

• Risperidon 2 x 2 mg

• Merlopam 1 x 5 mg

PROGNOSIS

Clinical : dubia at malam

Functional : dubia at malam

Social : dubia at malam

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