Bst Buk Linda

8/10/2019 Bst Buk Linda

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Bed Site Teaching

Gangguan Depresi Berulang Episode Kini Berat dengan Gejala

Psikotik

By

Taufik Ramadhani P. 1443

Harris Putra Reza P. 1449

PRECEPTOR

dr. Yaslinda Yaunin, Sp.KJ


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CASE REPORT

A 27 years old male patient, came to the

Mental Polyclinic of M.Djamil Hospital Padang

on August 25, 2014 at 01:00 pm and escortedby father. The complaints were frequent

crying, pensive, and speak for hisself since 3

weeks before coming to the hospital.


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PATIENTS IDENTITY :

Name : Mr S

Gender : Male

Place, Date of Birth/Age : Salido, August 8, 1987 /

27 years old. Marital status : Not married

Address : Kampung Laban KelurahanSalido Sari Bulan Pesisir

Selatan Occupation and School : Construction workers/

graduated from high school

Religion : Islam

Citizen : Indonesian


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Cardiovascular system :

Inspection :Ictus is not visible

Palpation : Ictus was palpable 1 finger on the

medial side of LMCS RIC V

Percussion :Cardiac border was obtained normal

Auscultation : Pure heart sounds, regular rhythm,

frequency 82x / min, no cardiac murmur

Gastrointestinal system :

Inspection :no bulge

Palpation :Liver and spleen were not palpable

Percussion : tympanic Auscultation : normal intestinal murmurs

specific abnormalities : not found


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NEUROLOGICAL STATUS

I. Central nervous System (sensory) : sight, smell,hearing, taste, and touch were fine

Symptoms of brain meningean stimulation : stiff necknegative

Symptoms of increase intracranial pressure : projectilevomitting negative, progressive headache negative

Eyes Movement : can be moved in any direction,

nistagmus negative

Perception : diplopia negative

Pupil : round, isochors,

Lights reflex : positive / positive

Convergence reflex : was not performed

Cornea reflex : was not performed

Ophthalmology : was not performed


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II. Motoric

Tone : Eutone

Turgor : good

Strength : 555 555

555 555

Coordination : Good

Reflex : Physiologic (patella): ++/++

Pathologic : Babinsky reflex negative

III. Sensibility : smooth and rough were good IV. Vegetative neuron: eating, sleeping, and waking

function were normal

V. Supreme functions: Activity of reading, writing, drawing,

language and numeracy can be performed


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V. Supreme functions: Activity of reading, writing,

drawing, language andnumeracy can be

performed well

VI. Spesific disorder stiffness : none

tremor : none

nasal stiffness : none

occulogiric crisis : none

torticolis : none


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Laboratory Test

26 Agustus 2014

HB = 14,9 g/dl Eritrosit = 4.740.000 /mm3

Ht = 44,4% Trombosit = 227.000 /mm3

Leukosit = 9.800 / mm3


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ALLOANAMNESIS

Name / Age : Mr. S/ 49 years old

Jenis Gender : Male

Address/phone :Kampung Laban Kelurahan Salido Sari

Bulan Pesisir Selatan/085263113XXX

Occupation : TPA Teacher

Education : Graduated form MTsN Relationship with the patient : Patient's father


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I. Main reason for hospitalization Patients burned his own pants and plunged into the pool 1

day before coming to the hospital.

Current Chief Complain: Patient fainted because of

hypotension 2 days ago and he often has a headache

since three weeks ago


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II. Past History of illness 2011

Patient worked in Batam as seasoning seller for six

months. After returning to his village, family was

aware of the changes inside him, such as pensive in

many times, speak for himself and do not respondwhen being called by the family. Patient feeled to be

squeezed by something and it went inside his body.


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Patient also often heared the whisper and he had

ever strangled his father, then the patient was taken

for treatment by his family to alternative medicine forabout 3 months. Because the family felt no change,

the patient was taken to M.Djamil hospital in Padang

and treated approximately 40 days. Patient went

home in a state of calm and did a routine control in

Painan hospital regularly.


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2014

Patient was not taking the drug because the drug

supply has been exhausted. Patient did not have time

to take prescription medicine so he did not consumethe medicine for about a week. Then he often cries,

being pensive, and speaks for himself since 3 weeks

before hospitalization. Patients also often hears the

voice of whisper which ask him to burn his house.Since 1 day before hospitalization, patient began to

burn newspapers and his own pants then walked

around on his own without direction and plunged into

a pool. Then the patient was referred to Dr.M.Djamil

Hospital in Padang.


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Premorbid History

Premorbid History

Infant : born spontaneously, term, attended by

midwives, no history of cyanosis, jaundice, or seizure.

Childhood : Growth and development were appropriate

with his age Teenage : Growth and development were appropriate

with teenagers on his age, before being ill, patient could

socialize well and had a lot of friends.


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III Educational Background

Elementary school : SDN 14 Laban in Salido,

graduated in 6 years, no achievement.

Junior high school : MTsN in Salido, graduated in 3

years, patient had ever been the champion of his class. Senior High School : SMAN 1 in Salido,

graduated in 3 years, no achievement.


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IV. Occupation History

Patient had ever worked for one year in

Malaysia as an employee of Supermarket.After that he worked for 6 months in Batam as

a cooking spice seller. During the past year,

he worked as a construction worker in Painan.


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V. Marital Status Not Married

VI. Socio-economic history Patient was living with his sister, parents, and two

nephews. The house is a permanent one, there is

electricity, the source of water is from wells.Patient had a motorcycle.


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VII Family History


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Graphic of illness

2011 2014


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Auto anamnesis

From Auto anamnesis we can concludethat:

the patient is cooperative, time

orientation is disturbed, Discriminativeinsight is disturbed, Discriminative

Judgement is disturbed, piromania is

present, there is a Visual, tactile andacustik hallucination, Sleeping less, and

decrease of appetite


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SUMMARY OF PSYCHIATRYCH TEST

I. General Appearance Conciousness/ sensorial : composmentis / good

Attitude : cooperative

Motoric : active Facial expression : rich

Verbalization : can speak, quite fluent

Psychic contact : could be done, appropriate, long

Attention : present

Initiative : less


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II. Specific condition

A. Affective

Affective condition : appropriate

Emotional :a. Stability : labil

b. Control : lessc. Echt/Unecht : Echt

d. Einfuhlung : inadequate

e. Deep/shallow : shallow

f. Differentiation scale : narrow

g. Emotional flow : slow


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B. Intelectual function and condition

a. Memorization ability : good b. Concentration : decrease

c. Orientation : disturbed in terms of time and

place

d. knowledge : hard to asses

e. Discriminative insight : disturbed

f. Intelligence prediction : normal average

g. Discriminative judgement : disturbed h. Intelectual decreasing : none


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C.Sensation and perception abnormalities a. illusion : none

b. hallucination

- accoustic : present

- visual : present

- olfatoric : none

- tactile : present


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D. Thought process condition

a. Speed of thought process : Slow

b. quality of thought : clear and sharp : clear and sharp

incoherent : none

Sperrung : none

Hemmung : Present

Flight of ideas : none

verbigeration : none

preservation : none


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C.Thought condition

Central pattern : none

phobia : none obsession : none

delusion : none

suspicion : none

confabulation : none repultion : none

inferior feeling : none

Much/little : little feeling guilty : present

hypochondria : none

others : none


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E.Instingtual drive and behaviour abnormalities

abulia : none

stupor : none

raptus/impulsivity : none

excitement state : none

sexual deviation : none

echopraxia : none

vagabondage : present

pyromani : present

mannerism : none

others : none


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Overt anxiety : present, much Reality testing ability : disturb in behaviour,

thinking and feeling


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MULTIPLE AXIS RESUME

Axis 1. Clinical Syndrome

Patient often cries, being pensive, and speaks for himselfsince 3 weeks before hospitalization, getting enough sleep

hours(7 hours a day) and enough meals (3 times a day).Sick was felt since 35 days ago. This is the second attack,

hospitalization for the second time too. The symptoms feltnow is more severe than the previous one.

General appearance: composmentis cooperative,

sensorial is fine, Attention is good, initiative is less, motoric

active, facial expression is rich, verbalization quite fluent,psychic contact could be done, normal and long.


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Specific condition

1.Affective condition : appropriate, labil, less, echt,

inadequate, shallow, narrow, slow.

2. Intelectual condition and function: memorization

ability good, hard to concentrate, orientation is disturbed

in terms of time and place, knowledge is hard to asses,

discriminative insight disturbed, intelligence prediction is

hard to asses, discriminative judgement

disturbed.Kelainan sensasi dan persepsi : halusinasi

ada (akustik dan taktil).

3. Sensation and perception abnormalities: no illusion,acoustic, olphactoric, and tactile hallucinations are

present


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4.Thought process condition : Slow, clear, sharp,and little.

5.Instinctual drive and behaviour abnormalities :

vagabondage present and piromania present.

6.Overt anxiety : present, much

7.Reality testing ability : disturbed in behaviour,

thinking and feeling


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Axis II.Personality Disorder and mental

retardation disorder

Personality : has many friends, prays

every day, obedient to his parents

Mental retardation : none


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Axis III. General medical condition

There's no history of malaria, typhoid, capitis trauma,and other disease that need to be hospitalized

Axis IV.Phsycosocial and environtment stressor Sudden stoped of consuming drugs 1 month ago.

Breaked of relationship with his girlfriend


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AxisV.Global assesment of function

Social relation activity (visiting friends, attending invitations,

gathering) could not be done totally since 5 weeks ago

such as

free time activity (watching TV, reading, recreation) couldnot be done well partially. Mostly spend his time at home,

no interest to have outdoor activity since 5 weeks ago

Daily activity (bathing, washing, working) could not be

implemented partially. :


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Multiple Axis Diagnose

Axis I : F 33.3 Recurrent depressive disorder

current episode severe with psychotic symptoms

Axis II : No Diagnose

Axis III : No Diagnose

Axis IV : Didnt take medication regularly

Axis V : GAF 41-50


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Differential Diagnose

F33.8 Other forms of Recurrent depressive disorder

F31.5 Bipolar Affective Disorders current episode

severe depressive with psychotic symptoms

F25.1 Schizoaffective disorder Depressive type


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Therapy

Haloperidol 2 x I @ 1,5 mg

Fluoxetin 1 x I @ 20mg

Trihexalphenidyl 2 x 1 @ 2 mg

Diazepam 1 x I @ 2 mg

Vitamin B kompleks 3 x I @ 50 mg

Vitamin C 3 x I @ 50 mg

Penilaian Good Bad


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Penilaian

Good

Bad

Onset

Teens

Relaps

Present

Diagnose

F33.3 Recurrentdepressive disorder

current episode severe

with psychotic symptoms

Family support

Present

Medical Response

Bad

State of Economy

Bad

Medication adherence

Not obedient

Precipitating factors

Clear

Family History None

Other Disease / Other None


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PROGNOSEClinical : Dubia et Malam

Functional : Dubia et bonam

Social : Dubia et bonam

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