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ILMU KESEHATAN
Supervisor
dr. Sabar Parluhutan Siregar, Sp.KJ
Disusun Oleh:
Maheksa Hayu Purnama (20184010004)
Reza Setyono Ashari (20184010022)
Lutfiana Arifah (20184010034)
Patient Identity
• Name : Mrs. T
• Born of Date : September , 27st 1975
• Age : 43 years old
• Address : Tegalrejo, Magelang
• Gender : Female
• Religion : Islam
• Ethnics : Javanesse
• Marital status : Married
• Occupational : Maid
• Education : Elementary school
• Date of entry : January, 6th 2019
• Date of examination: January, 8th 2019
KEDOKTERAN DAN
ILMU KESEHATAN
Family Identity
• Name : Mr. S
• Gender : Male
• Age : 45 years old
• Address : Magelang
• Occupational : Seller
• Relationship : Husband
• Intimacy : Closed
KEDOKTERAN DAN
ILMU KESEHATAN
ANAMNESIS
History was obtained by alloanamnesis and autoanamnesis
Alloanamnesis
Pushed her
Patient was
mother in law
advised when she
until felt down
was cooking rice She got angry
while her mother
with excessive
in law carrying
water
her baby
She also
easily got
Patient often tired when
Patient was daydreaming working
shocked and and spend her
felt scared time alone
Doctor told
that she must
do caesarean
surgery
USG: breech
presentation
KEDOKTERAN DAN
ILMU KESEHATAN
Fundal Height
40 weeks: fundus drops below 38
weeks. Levels as presenting part drops
into pelvis
36-38 weeks: fundus usually right up
under sternum
32 weeks: 2 cm under proc
xyphoideus
26 weeks: between umbilics & pro
xyphoideus
24 weeks: 2 cm under umbilicus
20 weeks: at umbilicus
14-16 weeks: 2 cm under umbilicus
12 weeks: fundus just above pubic
bone
KEDOKTERAN DAN
ILMU KESEHATAN
• Patient’s emotional aspects (showing what she wants, knowing her mistake,
crying or happy, if it was appropriate / inappropriate with what she want,
showing an empaty to her friend, describing her feeling or starting to develop
negative self image)
• Cognitive aspect (knowing functions of objects and synonyms/antonyms of
words. He had difficulties in learning. “Phallic stage” concepts by being curious
about human’s body, such as a curiosity of why there are differences between
male’s and female’s body parts. The “phallic stage” is the third stage of
psychosexual development in Freudian psychoanalysis (age of 3 – 5 or 6). At this
stage, children become aware of anatomical sex differences. There is no valid
data on patient’s cognitive aspect such as knowing function of object, knowing
the synonym or antonym of word, or grouping some object based on their same
character
• How patients parent suit her to learn or when her first time at school. There’s no
valid data about whether the patient still watering on her bed or not, or wether
she is still assisted when eating or not.
KEDOKTERAN DAN
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GENOGRAM
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DESCRIPTION OF ILLNESS
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PHYSICAL EXAMINATION
KEDOKTERAN DAN
ILMU KESEHATAN Internal Status
• Consciousness
Level of consciousness based of GCS remain
Compos mentis 15-14
Apatis 13-12
Delirium 11-10
Somnolen 9-7
Stupor 6-4
Coma 3
Respiratory Pattern
KEDOKTERAN DAN
ILMU KESEHATAN
Blood Pressure
Blood Pressure
Sistole BP (mmHg) Diastole BP (mmHg)
Classification
Pulse
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ILMU KESEHATAN
PHYSICAL EXAMINATION
• INTERNAL STATUS
1. Conciousnes : Composmentis (GCS E4V5M6)
2. Blood Pressure : 165/105 mmHg (stage 2 hypertension)
3. Heart Rate : 116x/minute, regular, filling and tension enough (N)
4. Respiration Rate : 18x/minute, regular, systemic, thoracoabdominal type
(N)
5. Temperature : 36.5°C, axilla (N)
KEDOKTERAN DAN
ILMU KESEHATAN
PHYSICAL EXAMINATION
• Head : normocephali (+), trauma (-), deformity (-)
• Eyes : conjungtival anemi (-/-), icterous sclera (-/-), pupil isochor (+), red eye (-/-)
• Nose : deformity (-), secrete (-/-), septal deviation (-), trauma (-), inflammation (-),
• Ears : normotia (+/+), secrete (-/-), inflammation (-), cerumen (+/+)
• Mouth: sianosis (-), drymouth (-), hyperemic mucous (-), Tonsil T1/T1, muscle
paralysis (-)
KEDOKTERAN DAN
Red Eyes Diagnostic Pathway
ILMU KESEHATAN
KEDOKTERAN DAN
ILMU KESEHATAN
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• Thorax
Cor
Inspection :deformity (-) scar (-) ictus cordis (-)
Palpation :ictus cordis is palpable on ICS V linea midclavicula sinistra
Percution :cor enlargement (-)
Auscultation:s1-s2 regular (+) heart murmur (-) s3 gallop (-)
Lung
Inspection :simetrical movement (+) use of accessory muscles (-) trachea
deviation (-)
Palpation :tactile fremitus (-) movement (-) pain (-)
Percution :sonor
Auscultation: vesicular sound (+/+) ronchi (-/-) wheezing (-/-) crepitation (-/-)
KEDOKTERAN DAN
ILMU KESEHATAN
• Abdomen
Extremity
• General Appearance
Body posture Normal
Abnormal movement -
Extremity
Motoric Upper limb Lower limb
Tonus + +
Power of movement 5 5
Clonus - -
Extremity
Sensoric Upper limb Lower limb
NEUROLOGICAL EXAMINATION
UPPER LIMB (PHYSIOLOGICAL REFLEX)
• Biceps Reflex (+/+)
• Triceps Reflex (+/+)
NEUROLOGICAL EXAMINATION
LOWER LIMB (PHYSIOLOGICAL REFLEX)
• Patella Reflex (+/+)
• Achilles Reflex (+/+)
NEUROLOGICAL EXAMINATION
Meningeal Sign
Kernig sign (-)
Brudzinsky I (-)
Brudzinsky II (-)
Brudzinsky III (-)
KEDOKTERAN DAN
ILMU KESEHATAN
NEUROLOGICAL EXAMINATION
Cerebellum Function Examination
• Heal to toe/ tendem gait test(normal)/ walking on staright line
• Romberg test (+) stand with closely foot and close eyes for 30
minutes
• Whist romberg test (+) stand with heel to toe foot and close eyes
for 30 minutes
• Dysdiadochokinesis (-) clap with alternating the palmar and dorsal
surface of the hand as fast as possible and repeat with other hand
• Finger to nose (-) nose to nose (-) finger to finger (-)
KEDOKTERAN DAN
ILMU KESEHATAN
Orientation
• People : good
• Time : good
• Place : good
• Situation : good
Psychic Contact
• Present (+) / absent
• Equitable (+)/ unequitable
• Constant (+) / non constant
KEDOKTERAN DAN
ILMU KESEHATAN
Attitude
Cooperative (+) Passive negativism (+)
Non cooperative Catalepsy
Indifferent Flexibilitas cerea
Apathy Excited
Tension
Dependent
Passive
Infantile
Labile
Rigid
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ILMU KESEHATAN
Verbal
• Quantity : increased / normal / decreased
• Quality : normal / decreased
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Perception
Visual
Hallucination
Olfactory
• Auditory (+)
Gustatory
• Visual (+)
Tactile
• Olfactory
Somatic
• Gustatory
• Tactile
• Somatic
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ILMU KESEHATAN
Thought Progress
Quality: Neologysm
Quantity: Irrelevant Circumstantiality
Logorrhea
Coprolalia Tangentiality
Talkactive
Flight of idea Vebrigeration
Blocking
Poverty of speech (+) Persevation
Remming (+)
Sound asosiation Word of salad
Mutism
Ecolali
Confabulation
Loosening assosiation
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ILMU KESEHATAN
Idea of suspicion
Thought of Content:
Delusion of control
• Idea of reference
Delusion of religion
• Pre-occupation (+)
Delusion of influence
• Obsession Thought of echo (+)
• Phobia Thought of insertion
• Fantasy Thought of withdrawal
• Delusion of persecution Thought of broadcast
• Delusion of reference Delusion of passivity
• Delusion of fault (+) Wisdom of greatness
• Delusion of enviour
• Delusion hypochondriac
• Delusion of magic-mistic
• Delusion of sin (+)
• Idea of succidal
KEDOKTERAN DAN
ILMU KESEHATAN
Thought of Form :
• Non-realistic (+)
• Dereistic
• Autistic
• Derealistic
• formatthought
• Illogical thinking
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ILMU KESEHATAN
Insight :
• Impaired insight (+)
• Intellectual insight
• True insight
Attention Conection :
• Attention easy to attracted, not able to sustained concentration
SYNDROME
• Auditory Hallucination
• Visual Hallucination
Schizophrenia • Thought of progress: Poverty of speech
Syndrome • Thought of content: thought of eco
• Thought of form: non-realistic
• Impaired insight
•Mood: dysphoric
•Affect: restrictive
Depression
•Remming
Syndrome
•Delusion of fault
•Delusion of sin
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ILMU KESEHATAN
Differential diagnosis
F 32.3
• Episode of severe depression with
psychotic symptoms
F 25.1
• Schizoaffective disorder, depressive type
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Axis I
• F 32.3 Episode of severe depression with psychotic
symptoms
Axis IV
• Pregnancy and baby birth
Axis V
• GAF 30 – 21
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List of problems
• Biological : neurotransmitter imbalance. Especially at the
mesolimbic pathway that cause + symptoms
• Psychological : hallucination auditoric, hallucination
visual, delusion of fault, delusion of sin, remming, poverty of
speech.
• Sociological : self-withdrawal, low self confidence, ADL
decreased
KEDOKTERAN DAN
ILMU KESEHATAN
• Maintenance therapy
Due to her dominant positive psychotic symptoms, she will be
given
Haloperidol tab 5 mg/12 hours per oral
Non-pharmacological therapy
• Psycho-education for patient and family, include
– Explanation about the illness of the patient
– The drug that must be consumed by the patient
include benefits, how to consumed, and the side
effects.
– Motivate the patient and family for came to control in
time
– Motivate the patient to re-do daily activities gradually
KEDOKTERAN DAN
ILMU KESEHATAN
PROGNOSE
PREMORBID
• History of psychiatric disorders in the family (none) : Good
• Marital status (married) : Good
• Family support (lack of treatment compliance support) : Good
• Socioeconomic status (enough) : Good
• Stressor (clear) : Good
• Premorbid personality (extrovert) : Good
MORBID
• Onset age : 43 y.o (Good)
• Type of disorder : Psychotic (Bad)
• History of disease : None (Good)
• Organic disorder : None (Good)
• Insight : impaired (Bad)
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