Post on 07-Feb-2016
description
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.