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Preseptor:
Dr. Yaslinda Yaunin, Sp.KJ(K)
A woman, 62 years old entered to
General Hospital M. Djamil Padang
Patient entered on December 9th,
2014, accompanied by her son in
law.
Chief complain
The patient raged violently, took the fire, held the
knife, talked alone, laughed alone, danced alone,
walked alone without direction.
Recent history
The patient raged violently, took the fire, held the knife,
talked alone, laughed alone, danced alone, walked alone
without direction since one day before admission.
One month before admission, patient came to Medan to
visit her youngest brother. There, the patient got hard
pressure from her brother. When the patient wish to came
back to Batusangkar, the brother refused her wish. Her
brother have rough personality. So, the patient had
pressure. She sat alone in the traffic light in Medan. She
had pee in the people’s home. Then, her brother took the
patient to Batusangkar.
Recent history
Arrived at home in Batusangkar, the patient raged
violently, took the fire, held the knife, talked alone,
laughed alone, danced alone, walked alone without
direction. Then, the son in law took the patient to the
general hospital M. Djamil, Padang.
Patient lives alone since 2 years ago. Previously, she lived
with her daughter and son in law and 3 grandsons. The
patient decided to live alone because she felt like to be
alone and didn’t like to be bridled. The daughter and family
visited the patient once a week; the distance is about one
km.
On 2010, the patient had suspicious to her neighbors. She
felt that the neighbors liked to talk about her, competed
her and others, ordered her anything.
Previous history
Psychiatry disorder history
On 2013, the patient had psychiatry disorder like talked alone,
walked alone without direction, and danced alone. Then, her
daughter and son in law took the patient to indigenous
medical practitioner. The practitioner didn’t give some
traditional medicine, but only gave some magic formula to
patient. The patient got better.
Medical disorder history
The patient didn’t have some medical history disease, surgery
history, accident history, neurologic disorder, tumor,
convulsion, consciousness disorder, HIV, etc.
Alcohol and addictive substance using history
There is no history of using nicotine, alcohol, morphine, etc.
Private history
Prenatal/ Perinatal period
Patient was born as the 4th child of 6 siblings. In the
pregnancy, patient’s mother had no disease and no consume
of medicine. Patient was born on time and norm weight. The
pregnancy was helped by indigenous medical practitioner
and cried.
Early pediatric period (0-3 years)
Patient grew and developed healthy like others.
Middle pediatric period (3-11 years)
Patient grew and developed healthy like others, had friends.
Late pediatric period and adolescence period
Patient grew and developed healthy like others, had friends.
Private
Adult period
history
Education history
The patient got education until 2nd grade of elementary school.
Job history
The patient is a vegetable seller. There is no conflict among sellers.
Marriage history
The patient had two times of marriage. First marriage with first husband was divorced
because of dishonesty. The husband was back to his first wife. Then, the patient married
for the second time, got one daughter. They divorced on 1978 because patient felt that the
second husband was lazy, less in attention and didn’t have hard work. 2 years ago, her ex-
second husband died, she didn’t depress.
Religion history
The patient is Muslim. She believes to god and prays 5 times a day. She read Quran. There
is no conflict to other faith.
Psychosexual history
There is no history of psychosexual history.
Social activity
The patient and neighbor had conflict. The patient felt that everyone was talking about
her.
Violation of law history
There is no history of violation of law.
Family history
Family history
Patient’s eldest sister had psychiatric disorder. Her
sister liked to be alone, keep silent, and not interested
in talking each other. According to the family, it
happened because she got the magic formula after
eating food in a meeting. There is no medical record
history including admission and control to doctor.
Recent life situation
The patient lives alone in the house since 2 years ago.
Previously, she lived with her daughter, son in law and
3 grandsons. Recently, they usually visit the patient
once a week. Their communication is good. Patient
lives in an old house, like a cottage. There is no vehicle,
there is electricity, and the water is from PDAM. The
salary got from herself as vegetable seller and youngest
brother from Medan as rice seller. Family didn’t know
the number she got every month. The salary is enough
for her daily needs.
Family’s perception and hope
Family wanted the patient get well soon.
Patient’s perception and hope
The patient needed to come home. She wanted to
meet her family especially her grandsons.
Internal Status
General Condition: Moderate ill
Awareness: Composmentis
Blood pressure: 130/90 mmHg
Pulse: regular, strong lift, frequency 83 times/minute
Respiration: moderate, torachoabdominal, frequency
20 times/minute
Temperature: Afebril
Height: 157 cm
Weight: 58 kg
Nutritional status: well
Cardiovascular system
Inspection :Ictus cordis not visible
Palpation :Ictus palpable around one finger medial to left
midclavicular line, 5th intercostal space
Percussion :Up: 2nd intercostal space, left: one finger
medial to left midclavicular line, right: dextra sternalis line
Auscultation: normal and regular heart sound,
murmurs absent
Sistem Respiratorik
Inspection :Simetric statically and dinamically
Palpation :Fremitus similar between left and right chest
Percusion :Sonor all over the thorax
Auscultation: Vesicular breath sound present, ronchi
absent, wheezing absent
Specific abnormalities :-
Neurologic Status
GCS : E4M6V5
Meningeal Sign : absent
Extrapiramidal sign
Hand tremor : absent
Akatisia : absent
Bradikinesia : absent
Way of stepping: normal
Balance : non disturbed
Rigiditas : absent
Motoric : freely in any direction
Sensorik : well propioseptif and exteroseptif
Refleks : Phisiologic reflex (+), phatologic
reflex (-)
Pertanyaan Jawaban Interpretasi
Siang buk. Saya Iyo, Compos mentis
dokter muda Wulan Buliah nak Cooperative
dan ini dokter muda
Rina. Buliah kami
tanyo ibuk subanta?
Psychotherapy :
Patient
Supportif psycotherapy
Psychoeducation
Family : Psychoeducation about
Patient disorder
Teraphy
PROGNOSIS