Bed side teaching

WULAN PRISILLA P.1512

AMRINA RASYADA P.1513

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?

Sia namo ibuk? Baidar Personal orientation

intact

Bara umua ibuk kini? 54 tahun

Tahun bara ibuk Tahun 57
lahir? Time orientation
Hari apo memangnyo Hari Selasa disturbed
kini tuh buk?
Pertanyaan Jawaban Interpretasi
Baa kok ibuk dibaok Ndak tau doh nak,
kamari? minantu ibuk ngajak
ka tampek si Nur. Siap
itu ibuk dikabek. Pak
dokter mambaok Discriminative insight
kamari. Subang, hape disturbed
samo barang ibuk Situational orientation
diambiaknyo dek intact
minantu. Kalau ado Suspicious (+)
inyo pasti ilang
barang ibuk.
Waktu itu baa kok Ndak tau ibuk doh
dikabek ibuk?
Manuruik ibuk, Ndak ndak. Ibuk ndak
patuik ndak ibuk malawan doh. Ibuk Discriminative
kanai kabek? manangih ajo dek judgment disturbed
kanai kabek.
Pertanyaan Jawaban Interpretasi
Manuruik ibuk, Ndak ndak. Ibuk ndak
patuik ndak ibuk malawan doh. Ibuk Discriminative
kanai kabek? manangih ajo dek judgment disturbed
kanai kabek.
Ibuk tau kini sadang Dirumah sakik
dima? Padang
Spatial orientation
Kalau dari rumah Lewat Padang
intact
ibuk ka Padang, awak Panjang
lewat ma buk?
Jadi apo nan taraso di Ndak ado
ibuk kini?
Sabalumnyo, ibuk ado Ndak nak Acustic halutination
maraso dibisiakkan (-)
sesuatu?
Kalau raso diraba- Ndak ado doh nak Tactil halutination (-)
raba atau dipegang?
Kalau maliek bayang- Ndak ado Visual halutination (-)
Pertanyaan Jawaban Interpretasi
Acok ibuk membau- Ndak juo doh nak Olfactory halutination
bau sesuatu yang (-)
busuak tapi ndak
jaleh dari ma asalnyo?
Ibuk ado maraso Indak pernah, tapi iyo
dandam atau banci ka tetangga ibuk suka
urang maotaan ibuk Animosity/revenge (+)
Tentang apo ibuk Pokoknyo tetangga
diotaannyo? tuh sirik ka ibuk
Ibuk pernah maraso Ndak pernah nak Inferior feeling (-)
ndak baguno?
Kalau kalua dari siko Ndak ado, ibuk nio Abulia (-)
ibuk nio manga? katamu cucu
Apak masih ado buk? Nyo alah maningga.
Laki ibuk. Pertamo Animosity/revenge (+)
pajudi. Kaduo pamain
padusi.
Pertanyaan Jawaban Interpretasi
Bara urang anak ibuk Suami pertamo ndak
dari suami tadi? dapek anak. Kaduo
ado anak surang
Jadi apak masih ado Alah maningga nak.
kini buk? Tapi alah lamo pisah Personal orientation
samo ibuk intact
Maaf buk, kalau jo Nyo selingkuh nak
suami pertamo
pisahnyo karno apo
buk?
Iyolah buk. Makasih Iyo nak
banyak waktunyo
buk. Kami pamit dulu.
General Condition
a. Awareness: Composmentis Attention : intact
b. Attitude : Cooperative Inisiative : present
c. Motoric behaviour: active
d. Facial expression: rich
e. Speech and verbal: speak fluently and clearly
f. Physical contact : can be done, natural, and long-time
Spesific condition
A. Natural State of Feeling
1. Afective condition : euthym
2. Emotion Living
a. Stability : stabile
b. Control : controlled
c. ech – unecht : echt
d. einfuhlung ( invoelaarhaid ) : inadequate
e. deep-shallow : shallow
f. differentiation scale : narrow
g. emotion flow : slow
Intelectual Funnction
Memory (amnesia) : less
Concentration : well
Orientation
( time, spatial, personal, situation): time orientation
disturbed
general knowledge : less
discriminative insight : disturbed
alleged level of intelegency : in normal avarage
discriminative judgment : disturbed
intelectual deterioration : no
Perseption and sensation anomaly
a. illution : absent
b. halutination - acustic : absent
- visual : absent
- olfatorik : absent
- tactil : absent
Way of Thingking
1. Psikomobilitas: slow
2. Thingking process
clear and sharp : clear but not sharp
Sirkumstansial: absent
Inkoherrent: absent
Sperrung : present
Hemmung : present
Flight of ideas : absent
Verbigerasi Persevarative ( Persevaratich ): absent
Contents
 Central pattern : absent
 Phobia : absent
 Obsess : absent
 Dellusion : absent
 Suspicion : present (to her son in-law)
 Confabulation : absent
 Animosity/revenge : present
 Inferior feeling : absent
 Much/less : much
 Guilty feeling : absent
 Hippochondria : absent
Instinctual impulse disorders
 Abulia : absent
 Stupor : absent
 Raptus / impulsivitas : absent
 excitement state : absent
 sexual deviation : absent
 Echophraxia : absent
 Vagabondage : absent
 Piromani : absent
 Mannerisme : absent
Overt anxiety : absent
Relation to reality : undisrupted
Multiaxial Evaluation
Axis I. Clinical Syndrome
Raging violently, taking the fire, holding the knife,
talking alone, laughing alone, dancing alone, walking
alone without direction.
General condition: cooperative, active, speaking fluently
and clearly, psychic contact can be done for long
duration of time, attention intact.
Specific condition
 Natural state of feeling : euthym, stabile, good
controlling, echt, inadequate einfuhlung, shallow,
narrow differentiation scale, slow emotion flow
 Intellectual condition : memorizing abililty intact,
concentrarion ability intact, orientation intact,
discriminative disturbed, discriminative judgment
disturbed, intelligence level normal, intellectual
regression absent
 Sensation and perception disorder: absent of illusion
and hallucination.
 Process of Thinking: slow, clear but not sharp,
circumstancial absent, incoherrent absent, Sperrung
present, Hemmung present, flight of ideas absent,
verbigeration absent, phobia absent, delusion absent,
suspicion present, confabulation absent, animosity
and revenge present, inferior feeling absent, guilty
feeling absent, hypochondria absent.
 Instinctual encouragement: abulia absent, stupor
absent, raptus absent, excitement state absent, sexual
deviation absent, echophraxia absent,
vagabondage absent, pyromania absent, mannerisme
absent.
 Anxiety: absent
 Relation to reality: undisrupted
Axis II. Personality disorder and mental retardation
 No diagnosis
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.
Axis IV. Psychosocial and environment
 Divorced
 Less of attention

Axis V. Global Assessment of Functioning

 Moderate symptomp and disabilities
MULTIAXIAL DIAGNOSIS
I. F. 25.0 Schizoaffective Disorder with Manic Type
II. None
III. None
IV. Divorced
V. GAF 60-51
DIFFERENTIAL DIAGNOSIS
1. F. 20.0 Paranoid Scyzophrenia
2. F. 20.3 Undifferentiated Scyzophrenia
THERAPY
Pharmacotherapy :
 Haloperidol 5mg 3x1 tablet
 Vit.B 50mg 3x1 tablet
 Vit.C 50mg 3x1 tablet

Psychotherapy :
Patient
 Supportif psycotherapy
 Psychoeducation
Family : Psychoeducation about
 Patient disorder
 Teraphy
PROGNOSIS

 Quo ad vitam : dubia ad bonam

 Quo ad fungsionam : dubia ad bonam
 Quo ad sanactionam : dubia ad malam
CASE ANALYSES
 The diagnosis of the patient got from history and physical
examination. Patient’s chief complains are raging violently, taking
the fire, holding the knife, talking alone, laughing alone, dancing
alone, walking alone without direction since one day before
admission. Physical examination shows normal blood pressure of
130/90 mmHg. Cardiovascular, respiratory, gastrointestinal, and
neurologic examination shows no abnormalities.
 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. 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.
CASE ANALYSES
 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. 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.
 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. 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.
 CASE ANALYSES
 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.
 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.
 Psychic contact can be done, proper, persist for long
duration, euthym, stabile, good controlling, echt,
shallow, narrow differentiation scale, slow emotion
flow Intellectual function unimpaired. There are
disturbed discriminative insight and judgment also
present of Sperrung and Hemmung in thinking
process.
 Patient is diagnosed scyzoafective disorder with manic type
as stated in the PPDGJ-III. The symptoms consist of
disturbed time orientation, present of animosity and
revenge, suspicious to her son in-law and neighbourhood
also unimpaired sensation and perception. These
symptoms are not obvious nor diagnostic. Might be the
examination was not perform in early time and patient
have gotten some drug prescribed. So these minimalize or
loss diagnostic symptomps. Triggering event is not clear.
Her divorce with her husband is believed to play a role in
present symptom also less attention from her only child
make the condition worse.
 Given Prognosis to this patient is bad, because the
disease has repeated and there is no adequate family
support. Patient is given haloperidol 5mg 3x1 tablet, B
vitamine 50mg 3x1 tablet, and C vitamine 20 3x1 tablet.
SCHEME OF DISEASE HISTORY