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TRANSCRIPT
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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