Bed side teaching

Thursday/ January 22th, 2015

Afective Disorder Severe Depressive Episode with

Phsycotic Symptoms

By : Mailia Ulfa P1519

Meishinta Fitria R1517

Preceptor : dr. Yaslinda Yaunin, Sp.KJ

DEPARTMENT OF PSYCHIATRI

MEDICAL FACULTY OF ANDALAS UNIVERSITY

GENERAL HOSPITAL OF M.DJAMIL – PSYCHIATRI HOSPITAL HB

SAANIN

PADANG

2015

0

I. IDENTITY OF PATIENT

Name : Mr. ER

Sex : man

Age : 40 years old

Religion : Moslem

Ethnic : Minangkabau

Last education : graduated of Junior high school

Job : no job

Marriage : Divorced

Address : Jati Parak Salai Street Number 49 Padang

Handphone number : 085363747***

Patient entered the hospital on January 17th, 2015, accompanied by his

young sisters.

II. HISTORY OF PSYCHIATRI

Data was get by:

- Autoanamnesis on January 21th, 2015.

- Alloanamneis to:

Young sister (Surya Lina, 27 years old ) on January 21th, 2015

- Medical record.

A. Chief Complain

The patient rampage and intending to burn his house.

B. Recent History

- Initially, patient was asleep, then patient heard voice of televi-

sion and water while his young sister was washing. Patient

rampage and told his young sister to turn off television and

water. After that, the patient laughed and suddenly cried. Pa-

tient intending to burn his home because get headache after

the incident earlier.

- Patient often pretend unconscious.1

- Nude when out of the house absent, previous present 5 month

ago.

- His young sister said, he often drink water from the tub

- Eating and sleeping enough.

- His young sisters said that the patient had heard a whisper that

intangible that getting patient to change religion.

- He always angry if he look his young sister sit together with

her husband

C. Previous History

1. Psychiatry disorder history

- Patient has no history to hurt another or to injur himself.

- On 2000, the patient’s father died. Patient more often dreamy,

moody, and suddenly cried. Patient locked himself in the

room. Patient are not taken for treatment by his family.

- On 2003, the patient suddenly left the house and went without

a clear purpose. He left his wife. He more often dreamy,

moody, and suddenly cried.

- On 2009, his mother was died.

- On 2014, he rampage and angry because of his desire to marry

again not release. He was taken to RSUP M. Djamil and

treated for 25 days.

2. Medical disorder history

The patient didn’t have some medical history disease,

surgery history, accident history, neurologic disorder, tumor, con-

sciousness disorder, HIV.

D. Private History

1. Prenatal/ Perinatal period

Patient was born as the 3th child of 9 siblings. Patient was born on

time and norm weight. The pregnancy was helped by indigenous

medical practitioner and cried.

2

2. Early pediatric period (0-3 years)

Patient grew and developed healthy like others.

3. Middle pediatric period (3-11 years)

Patient grew and developed healthy like others, had friends.

4. Late pediatric period and adolescence period

Patient grew and developed healthy like others, had friends.

5. Adult period

a. Education history

The patient got education until junior high school.

b. Job history

The patient work in Yos Sudarso Hospital as Cleaning Service

1994-1997. In 1997, he resign because he often listened to

whisper asking him to convert his religion.

c. Marriage history

He married in 2000 but, in 2003 he left his wife

d. Religion history

The patient is Moeslim. He believes to god but he don’t prays

5 times a day.

e. Psychosexual history

There is no history of psychosexual history.

f. Social activity

The patient and neighbor had no conflict.

g. Violation of law history

There is no history of violation of law.

3

E. Family History

Explanation : : Man

: Woman

: Family with phsyciatric disorder

: living with patient

F. Recent life situation

The patient lives with his sister in the house. Their communication is

good.

G. Family’s perception and hope

Family wanted the patient get well soon and continue his live.

H. Patient’s perception and hope

The patient wanted get well soon and continue his live.

III. Internal Status

General Condition : Moderate ill

Awareness : Composmentis

Blood pressure : 120/80 mmHg

Pulse : regular, strong lift, frequency 83

times/minute

Respiration :moderate, torachoabdominal, frequency 21

times/minute

Temperature : Afebril

Height : 160 cm4

patient

Weight : 55 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

Respiratoric System :

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 : -

IV. 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 direction5

555 555 555 555

- Sensorik : well propioseptif and exteroseptif

- Refleks : Phisiologic reflex (+), phatologic reflex (-)

V. Mental Status

Autoanamnesa

Pertanyaan Jawaban Interpretasi

Siang pak Eri. Ambo dokter

muda Shinta dan iko dokter

muda Ulfa. Buliah kami

tanyo tanyo subanta pak?

Iyo Compos mentis

Sia namo ? Erizal Rasyid Personal orientation intact

Bara umua kini pak? 40 tahun

Time orientation not

disturbeTahun bara kini pak? Tahun 2015

Bulan apo kini pak? Bulan 1

Tanggal bara kini ko pak? 22

Manuruik apak patuik ndak

apak dibaok kamari

Ndak tau Discriminative insight

cannot be evaluated

Kecek keluarga apak, apak

pernah minum air bak

mandi. Iyo bana tu pak?

(diam)Discriminative judgment

cannot be evaluated

Apak tau kini sadang dima? Dirumah sakik M.

JamilSpatial orientation intact

Jadi apo nan taraso kini

ilham?

Sakik kapalo

Sabalumnyo, apak ado

maraso dibisiakkan

sesuatu?

(diam) sakik kapalo Acustic halutination (canot

be evaluated)

Kalau raso diraba-raba atau

dipegang?

(diam) sakik kapalo Tactil halutination (canot

be evaluated)

Kalau maliek bayang-

bayangan?

(diam) Visual halutination (canot

be evaluated)

Ado membau-bau sesuatu

yang busuak tapi ndak jaleh

(diam) Olfactory halutination

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dari ma asalnyo? (canot be evaluated)

ado maraso dandam atau

banci ka urang ndak pak?

(senyum) Animosity/revenge (canot

be evaluated)

Pernah maraso ndak

baguno?

(diam) Inferior feeling (canot be

evaluated)

Kalau abis dari siko nio

manga apak lai?

Nio pulang Abulia (-)

Bara urang apak

basaudara?

Sambilan

Ok makasih yo pak (diam)

Based on the examination in January, 21th 2015

I. General Condition

Awareness : Composmentis Attention : less

Attitude : Cooperative Inisiative : less

Motoric behaviour : hypoactive

Facial expression : poor

Speech and verbal : speak less and not clearly

Physical contact : can be done, natural, and short-time

II. Spesific condition

A. Natural State of Feeling

1. Afective condition : hipothym

2. Emotion Living : a. Stability : labil

b. Control : controlled

c. ech – unecht : echt

d. einfuhlung ( invoelaarhaid ) : inadequate

e. deep-shallow : shallow

f. differentiation scale : narrow

g. emotion flow : slow

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B. Intelectual Funnction

a. Memory (amnesia) : well

b. Concentration : inadequat

c. Orientation

( time, spatial, personal, situation) : good

d. general knowledge : good

e. discriminative insight : cannot evaluated

f. alleged level of intelegency : cannot evaluated

g. discriminative judgment : cannot evaluated

h. intelectual deterioration : absent

C.Perseption and sensation anomaly

a. illution : cannot evaluated

b.halutination - acustic : cannot evaluated

- visual : cannot evaluated

- olfatorik : cannot evaluated

- tactil : cannot evaluated

D. Way of Thingking

1. Psikomobilitas : slow

2. Thingking process

a. clear and sharp : clear but not sharp

b. Sirkumstansial : absent

a. Inkoherrent : absent

b. Sperrung : cannot evaluated

c. Hemmung : cannot evaluated

d. Flight of ideas : cannot evaluated

e. Verbigerasi Persevarative ( Persevaratich ) : absent

3. Contents

a. Central pattern : cannot evaluated

b. Phobia : cannot evaluated8

c. Obsess : cannot evaluated

d. Dellusion : cannot evaluated

e. Suspicion : cannot evaluated

f. Confabulation : cannot evaluated

g. Animosity/revenge : cannot evaluated

h. Inferior feeling : cannot evaluated

i. Much/less : less

j. Guilty feeling : cannot evaluated

k. Hippochondria : cannot evaluated

l. Others : -

E. Instinctual impulse disorders

a. Abulia : cannot evaluated

b. Stupor : absent

c. Raptus / impulsivitas : absent

d. excitement state : absent

e. sexual deviation : absent

f. Echophraxia : absent

g. Vagabondage : cannot evaluated

h. Piromani : absent

i. Mannerisme : absent

j. Others : -

F. Overt anxiety : cannot evaluated

G. Relation to reality : cannot evaluated

VI. Multiaxial Evaluation

Axis I. Clinical Syndrome

Rampage, intending to burn his home

General condition: cooperative, active, speaking less and clearly, psychic contact

can be done for short duration of time, attention intact.9

Specific condition

Natural state of feeling : hypothym, labil, good controlling, echt,

inadequate einfuhlung, shallow, narrow differentiation scale, slow emotion

flow

Intellectual condition : memorizing abililty well, concentrarion ability

well, orientation good, general knowledge good, discriminative insight

cannot evaluated, allegged level of intelegency cannot evaluated,

discriminative judgment cannot evaluated, intellectual deterioration absent

Sensation and perception disorder: illusion and hallucination cannot evalu-

ated.

Process of Thinking: slow, clear but not sharp, circumstancial absent, in-

coherrent absent, Sperrung cannot evaluated, Hemmung cannot evaluated,

flight of ideas cannot evaluated, verbigeration absent, central pattern can-

not evaluated, phobia cannot evaluated, delusion cannot evaluated,

suspicion cannot evaluated, confabulation cannot evaluated, animosity and

revenge cannot evaluated, inferior feeling cannot evaluated, less, guilty

feeling cannot evaluated, hypochondria cannot evaluated.

Instinctual encouragement: abulia cannot evaluated, stupor absent, raptus

absent, excitement state absent, sexual deviation absent, echophraxia

absent, vagabondage cannot evaluated, pyromania absent, mannerisme ab-

sent.

Anxiety: cannot evaluated

Relation to reality: cannot evaluated

Axis II. Personality disorder and mental retardation

Unstable emotionally personality disorders

Axis III. General Medical Condition

No history of head trauma, malaria, typhoid, and other disease which

needs hospitalization. No history of alcohol and drugs consumption.

There is no mental retardation

Axis IV. Psychosocial and environment

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No diagnosis

Axis V. Global Assessment of Functioning

80-71: Symptoms temporary and can be overcome, mild disability in so-

cial, work and school.

MULTIAXIAL DIAGNOSIS

I. F.32.3 Afective Disorder Severe Depressive Episode with Phsycotic

Symptom

II. Unstable emotionally personality disorders

III. No diagnosis

IV. No diagnosis

V. GAF 80-71

DIFFERENTIAL DIAGNOSIS

1. F31.5 Bipolar affective disorders severe depressive now episode, with psy-

chotic symptoms

2. F25.1 Depressive type skizoafective disorder

THERAPY

A. Pharmacotherapy :

Risperidon 2 x ½ tab @ 2 mg

Trifluoperazin 3 x (1/2 - 1 - 1) tab @ 5 mg

Amitriptyline 2 x ½ tab @ 25 mg

Chlorpromazin 1 x 1 tab @ 100 mg (malam)

B. Psychotherapy :

1. Patient

Supportif psycotherapy

Psychoeducation

2. Family : Psychoeducation about

Patient disorder

Teraphy11

PROGNOSIS

Quo ad vitam : dubia ad bonam

Quo ad fungsionam : dubia ad bonam

Quo ad sanactionam : dubia ad bonam

XII. CASE ANALYSES

The diagnosys of the patient got from history and physical examination.

Patient’s chief complains rampage and intended to burn his home. Physical exam-

ination shows normal blood pressure of 120/80 mmHg. Cardiovascular, respira-

tory, gastrointestinal, and neurologic examination shows no abnormalities.

A few hour before admission, patient was asleep, then patient heard voice of

television and water while his young sister was washing. Patient rampage and told

his young sister to turn off television and water. After that, the patient laughed and

suddenly cried. Patient intending to burn his home because get headache after the

incident earlier. He was taken to RSUP M. Djamil

On 2000, the patient’s father died. Patient had psychiatry disorder like

dreamy, moody, and suddenly cried. Patient locked himself in the room. Patient

are not taken for treatment by his family.

Psychic contact can be done, natural, persist for short duration, hypothym,

labile, good controlling, echt, shallow, narrow differentiation scale, slow emotion

flow Intellectual function cannot evaluated. Discriminative insight, Sperrung, He-

mmung discriminative judgement cannot evaluated.

Patient is diagnosed with Afective Disorder Severe Depressive Episode with

Phsycotic Symptom as stated in the PPDGJ-III. Patient is given Risperidon 2 x ½

tab @ 2 mg, Trifluoperazin 3 x (1/2 - 1 - 1) tab @ 5 mg, Amitriptyline 2 x ½ tab

@ 25 mg, Chlorpromazin 1 x 1 tab @ 100 mg (malam).

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SCHEME OF DISEASE HISTORY

0

On 2000, the patient’s father died. Patient more often dreamy, moody, and suddenly cried own. Patient locked himself in the room. Patient are not taken for treatment by his family.

On 2009, his mother was died.

On 2003, the patient suddenly left the house and went without a clear purpose. He left his wife. He more often dreamy, moody, and suddenly cried.

2015. Initially, patient was asleep, then patient heard voice of televi-sion and water while his young sis-ter was washing. Patient rampage and told his young sister to turn off television and water. After that, the patient laughed and suddenly cried. Patient intending to burn his home because get headache after the inci-dent earlier. He was taken to RSUP M. Djamil

On 2014, he rampage and angry because of his desire to marry again not release. He was taken to RSUP M. Djamil and treated for 25 days.