Bed side teaching

Thursday/ February 12th, 2015

Afective Disorder Severe Depressive Episode with

Phsycotic Symptoms

By : Trisno Susilo P15

Hasnal Laily Yarza P1539

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
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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
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.
- Patient often pretend unconscious.
- 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.

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 - 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,
consciousness 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. 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
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 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.

E. Family History

patient
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

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 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 cm
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
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 - Way of stepping: normal
- Balance : non disturbed
- Rigiditas : absent
- Motoric : freely in any direction
- Sensorik 555 555propioseptif and exteroseptif
: well
- Refleks 555 555
: Phisiologic reflex (+), phatologic reflex (-)

V. Mental Status
Autoanamnesa
Pertanyaan Jawaban Interpretasi
Siang pak Eri. Ambo dokter Iyo Compos mentis
muda Shinta dan iko dokter
muda Ulfa. Buliah kami
tanyo tanyo subanta pak?
Sia namo ? Erizal Rasyid Personal orientation intact
Bara umua kini pak? 40 tahun
Time orientation not
Tahun bara kini pak? Tahun 2015
disturbe
Bulan apo kini pak? Bulan 1
Tanggal bara kini ko pak? 22
Manuruik apak patuik ndak Ndak tau Discriminative insight
apak dibaok kamari cannot be evaluated
Kecek keluarga apak, apak (diam)
Discriminative judgment
pernah minum air bak
cannot be evaluated
mandi. Iyo bana tu pak?
Apak tau kini sadang dima? Dirumah sakik M.
Spatial orientation intact
Jamil
Jadi apo nan taraso kini Sakik kapalo
ilham?
Sabalumnyo, apak ado (diam) sakik kapalo Acustic halutination (canot
maraso dibisiakkan be evaluated)
sesuatu?
Kalau raso diraba-raba atau (diam) sakik kapalo Tactil halutination (canot
dipegang? be evaluated)
Kalau maliek bayang- (diam) Visual halutination (canot
bayangan? be evaluated)
Ado membau-bau sesuatu (diam) Olfactory halutination
yang busuak tapi ndak jaleh (canot be evaluated)
dari ma asalnyo?
ado maraso dandam atau (senyum) Animosity/revenge (canot

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 banci ka urang ndak pak? be evaluated)
Pernah maraso ndak (diam) Inferior feeling (canot be
baguno? evaluated)
Kalau abis dari siko nio Nio pulang Abulia (-)
manga apak lai?
Bara urang apak Sambilan
basaudara?
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
B. Intelectual Funnction
a. Memory (amnesia) : well
b. Concentration : inadequat
c. Orientation
( time, spatial, personal, situation) : good
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 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 evaluated
c. Obsess : cannot evaluated
d. Dellusion : cannot evaluated
e. Suspicion : cannot evaluated
f. Confabulation : cannot evaluated
g. Animosity/revenge : cannot evaluated
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 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.
Specific condition
 Natural state of feeling : hypothym, labil, good controlling, echt,
inadequate einfuhlung, shallow, narrow differentiation scale, slow emotion
flow

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  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
evaluated.
 Process of Thinking: slow, clear but not sharp, circumstancial absent,
incoherrent absent, Sperrung cannot evaluated, Hemmung cannot
evaluated, flight of ideas cannot evaluated, verbigeration absent, central
pattern cannot 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
absent.
 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
 No diagnosis

Axis V. Global Assessment of Functioning

 80-71: Symptoms temporary and can be overcome, mild disability in
social, work and school.

MULTIAXIAL DIAGNOSIS
I. F.32.3 Afective Disorder Severe Depressive Episode with Phsycotic
Symptom
II. Unstable emotionally personality disorders
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III. No diagnosis
IV. No diagnosis
V. GAF 80-71

DIFFERENTIAL DIAGNOSIS
1. F31.5 Bipolar affective disorders severe depressive now episode, with
psychotic 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
 Teraphy

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
examination shows normal blood pressure of 120/80 mmHg. Cardiovascular,
respiratory, 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
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 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,
Hemmung 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

On 2009, his 2015. Initially, patient was asleep,

On 2000, the mother was died. then patient heard voice of
patient’s father died. television and water while his
Patient more often young sister was washing. Patient
dreamy, moody, and rampage and told his young sister to
suddenly cried own. On 2014, he turn off television and water. After
Patient locked On 2003, the rampage and that, the patient laughed and
himself in the room. patient suddenly angry because of suddenly cried. Patient intending to
Patient are not taken left the house and his desire to burn his home because get
for treatment by his went without a marry again not headache after the incident earlier.
family. clear purpose. He release. He was He was taken to RSUP M. Djamil
left his wife. He taken to RSUP
more often dreamy, M. Djamil and
moody, and treated for 25
suddenly cried. days.