MUHAMAD AZRUL 0810314158 CHARAN PAL SINGH 0810314156 PRECEPTOR: dr. YASLINDA YAUNIN SP.

KJ

Name : Sari Bulan Gender : Female Age ` : 29 years old. Marital status : single Address : koto Napan, Sumut Occupation and School : Secondary school, not working Religion : Islam Citizen : Indonesian Race : Minangkabau

A 29 year old female patient was admitted to RSJ HB Saanin emergency department on April 26th, 2013 and escorted by her brother. This patient presented with signs such as anxiety, always being angry without reason, always talking to herself without sense, laughs herself even when there is no one around, sometimes she becomes emotional when things doesnt go on her needs.. She has delusion of greatness and thinks she is a famous artist. She has no problem in her eating habits. She threatened her family members with harsh words

Internal Status General appearance Blood pressure Pulse rate Temperature : : : : Compos Mentis 110/70 mmHg 86 x per minute 36,5 C No disorders found No disorder found No disorder found

Cardiovascular system : Digestive system Specific disorder : :

Neurological Status GCS 15, pupil reflex positive, corneal reflex positive No meningeal signs, no signs of increased intracranial pressure Cranial nerves Motoric : : No disorders found Eutonus, Eutrophic, no disorder, Muscle strength superior extremity 555/555, inferior extremity 555/555 Sensibility Specific disorder : : No disorder found No disorder found

ALLOANAMNESIS Was done on 20th May 2013 Alloanamnesis obtained from patients brother: Name Age Telephone : Salam : 44 years : : private company

Work & Education

Relation with patient : brother

1. Main reason of Hospitalization This patient presented with signs such as anxiety, always being angry without reason, always talking to herself without sense, laughs herself even when there is no one around, sometimes she becomes emotional when things doesnt go on her needs.. She has delusion of greatness and thinks she is an famous artist. She threatened her family members with harsh words

Present complaint of Illness Patient classified as Healthy without any complaint

1. History of Illness Year 2006 (Month unidentified) Patient was frequently anxious; always get angry if her need doesnt go with her desire. Always goes out during the night, threaten her family members with harsh words and was brought to the RSJ HB Saanin and was admitted

Year 2007-2012 (month unidentified) The patient was admitted regularly to the hospital for the same complaints She was brought to RSJ HB Saanin and was warded there. She has been in and out of the hospital for the past 6 years with the same complaints
Year 2013 (April till Present) Patient does not want to take regular medications, laughs without any reason, she has delusions of greatness as if she is a famous celebrity. The patient likes shopping. The patients also thinks she has graduated from university and obtained a degree.

3. Premorbid History Infant : born spontaneously, birth was assisted by midwife, no history of jaundice, cyanosis, or seizure. Childhood : growth and development suitable for her age. Adolescence: polite, had a lot of friends, easily make new friends and outgoing person Adult : have a lot of friends

4. Educational Background Primary School : completed primary school Secondary school : completed secondary school
5. Work history Patient has no working history 6. Socioeconomical status Lives with her elder brother in a permanent house, good electricity and water resources, with a color TV and motor vehicles.

1. Family History

Graphic of illness course

Years
2006 2007 2008 2009 2010 2011
2012 2013

Summary of Phsyciatric Examination

Counciousness Attitude Motoric Facial expression Verbalization Physic contact Attention Initiative

: compos mentis : cooperative : active : good : can talk, clearly and fluently : can be done, appropriate, long enough : present : present

II. Specific Condition A. Affective 1.Affective condition : hypertym 2. Emotional : a. Stability : stable b. Control : controlled c. Echt/unecht : echt d. Einfulung : inadequate e. Deep/shallow : shallow f. Differentiation scale : narrow g. Emotional flow : slow

B.

Intellectual condition of function a. Memory : enough b. Concentration : enough c. Orientation : time orientation good, special and persons orientation good d. Knowledge: undetermined e. Discriminative insight : not disturbed f. Intelligence prediction : average g. Discriminative judgment : not disturbed

C. 1. 2.

Sensation and perception abnormalities Illusion : none Hallucination : Acoustic : none Visual : none Olfactory: none Tactile : none Gustatory: none

D. Thought process condition 1. Speed of thought process :clear and appropriate 2. Quality of thought process: a. Clear and sharp :clear and sharp b. Incoherent : none c. Sperrung : none d. Hemmung : none e. Flight of ideas : present f. Verbigeration : none g. Preservation : none

3.

a. b. c. d. e. f. g. h. i. j. k. l.

Thought condition Central pattern : Phobia : Obsession : Delusion : Suspicion : Confabulation : Repulsion : Inferior feeling : Much/little : Feeling guilty : Hypochondria : Others :

none none none none none none none none little none none none

E. Instinctual drive and behavior abnormalities a. Abulia : none b. Stupor : none c. Raptus/impulsivity : none 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 : no disturbance

MULTIPLE AXIS RESUME Axis 1. Clinical syndrome Patient does not want to take regular medications, laughs without any reason, she has delusions of greatness as if she is a famous celebrity. The patient likes shopping. The patients also thinks she has graduated from university and obtained a degree.

Phyciatric examination General condition: compos mentis, cooperative, less initiative, hyperactive, verbalization is clear and sharp,talkative, psychic contact good, appropriate, long enough.

Specific condition : 1.Affective condition: hyperthym, stable, echt, 2.Intellectual condition of function: memory good, good concentration, time orientation is good, knowledge is difficult to evaluate, discriminative insight not disturbed, intelligence average, discriminative judgments not disturbed. 3.Sensation and perception abnormalities: no illusion ,no hallucination,

4.Thought process condition: fast, clear and sharp, circumstantial present, delusional, suspicious. 5.Instinctual drive and behavior abnormalities : no disturbance 6.Over anxiety : none 7.Reality testing ability : no disturbance in behavior, feeling and thinking

Axis II. Personal disorder and mental retardation disorder Personality disorder : none Mental disorder : none
Axis III. General medic condition No history of head trauma , or malaria which needed hospitalization.

Axis IV. Psychosocial stressor and environment None Axis V. Global assessment functional Social: likes shopping and going out at night Daily Activity: no disturbance. Leisure/ recreational activity: no disturbance.

Multiple Axis diagnosis I . F31.2 Bipolar Affective Disorder, Manic Episode with psychotic symptoms II. No Diagnosis III. No Diagnosis IV. No problems V .

Differential diagnosis F 31.8 Other Bipolar Affective disorders F 06.31 Organic Bipolar Affective disorder Therapy Chlorpromazine 1 x 1 tablet @ 100 mg Risperidone 1 x 2mg

Prognosis Clinical : dubia ad bonam Functional : dubia ad bonam Social : dubia ad bonam

Autoanamnesis
Dokter Muda Sore kak Perkenalkan nama saya dokter muda Azrul dan ini teman saya CP Bisa kami bertanya ke Bulan? Lagi ngapain tadinya? Udah makan? Sore doc Nama saya Bulan. Teman kamu ganteng sekali, hidungnya mancung Bisa abang Baru selesai mandi Makan alun siang alah, makan malam Pasien
Interpretation Cooperatif

Tau Bulan dimana sekarang? Udah berapa lama disini?

Tau, lagi di rumah sakit Udah hampir 1 bulan .

Orientation is not disturbed

Kenapa bias sampai disini? Baa tu? Sering ngak kedengaran suara suara, bisikan, Nampak bayangan, mencium bau?

Saya sakit jadi keluarga berobat Tidak ada bang .

dihantar

sama

Discriminatif insignt is good

Discriminatif judgement is good No hallusination

sekolah sampai kelas berapa bulan?

Saya kuliah ambil S.Pd tapi berhenti sampai semester 4. Tidak bias belajar,susah.

Delusion

Tinggalnya sama siapa bulan?

Tinggal sama keluarga bang.

Concentration is good