Bed Site Teaching

Recurrent Depressive Disorder Current Episode Severe With

Psychotic Symptoms

OLEH
Taufik Ramadhani

P. 1443

Harris Putra Reza

P. 1449

PRECEPTOR
dr. Yaslinda Yaunin, Sp.KJ

PSYCHIATRY DIVISION
MEDICAL FACULTY OF ANDALAS UNIVERSITY
RSUP DR. M.DJAMIL PADANG
2014

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 escorted by father. The
complaints were frequent crying, pensive, and speak for hisself since 3 weeks
before coming to the hospital.
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 Kelurahan Salido Sari Bulan Pesisir

Selatan

Occupation and School : Construction workers/ graduated from high school

Religion

: Islam

Citizen

: Indonesian

Race

: Minangkabau

INTERNAL STATUS
General appearance

: Medium

Blood pressure

: 120/80 mmHg

Pulse

: Palpable strong, regular, frequency 82 x / min

Breath

: Abdominaltorakal, regular, frequency 18 x / min

Temperature

: 38,1 C

Body shape

: Asthenikus

Height

: 155 cm

Weight

: 50 kg

Respiratory system

Inspection

: Symmetrical on both left and right site in static and

dynamic state

Palpation

: Fremitus left side equal to the right side

Percussion

: Sonor throughout the lung fields

Auscultation

: Vesicular breath sounds, no ronkhi, and no wheezing

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

NEUROLOGICAL STATUS
I.

Central nervous System (sensory) : sight, smell, hearing, taste, and touch
were fine
Symptoms of brain meningean stimulation : stiff neck negative
Symptoms of increase intracranial pressure : projectile vomitting 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

Ophthalmology

: was not performed

: was not performed

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
well

VI. Spesific disorder

-

stiffness

: none

tremor

: none

nasal stiffness

: none

occulogiric crisis

: none

torticolis

: none

Laboratory Test
26 Agustus 2014
HB = 14,9 g/dl
Ht = 44,4%
Platelet = 242.000 /mm3
Leukocytes = 9.280 / mm3

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

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

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 respond
when being called by the family. Patient feeled to be squeezed by
something and it went inside his body. 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 for about 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.
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 consume the medicine for about a week. Then he often

cries, being pensive, and speaks for hisself 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 jis 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.

Premorbid History
- Infant

: born spontaneously, aterm, 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.

III. Educational Background

Elementary school : SD 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 : SMA in Salido, graduated in 3 years, no

achievement.

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.
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.

Income
- Patients salary

Rp. 1.400.000,-/month

- Fathers salary as a TPA teacher

Rp.

Total

750.000,-/ month

Rp. 2.150.000,-/bulan

Expenditure :
- Cost of daily living

Rp. 1.800.000,-/bulan

- Cost of electricity

Rp.

Total

75.000,-/bulan

Rp. 1.875.000,-/bulan

Remaining money to save = 2.150.000 Rp 1.8750.000 = Rp 275.000

VII. Family History

VIII. Graphic of illness

2011

2014

AUTOANAMNESIS
Pertanyaan
Assalamualaikum,
perkenalkan da kami
dokter muda di siko.
Namo awak Harris, ko
kawan awak Taufik. Sia
namo uda?
Labiah nyaman ma uda,
dipanggia wando se atau
kami ba uda?
Uda labiah nyaman pakai
bahaso Indonesia atau
baso minang?
Wando buliah kami
batanyo tentang kondisi
Wando?

Jawaban
Walaikumsalam, namo awak
Wando(bersalaman).

Lah bara umua wando?

27

Interpretasi

Wando se lah langsuang

Kooperatif
Baso minang se lah.

Buliah

Tahun bara tu wando 1987

layia berarti wando?
Tanggal bara tu ndo?

8 Agustus 1987

Orientasi Waktu
terganggu

Kalau kini tahun bara Tahun 2014. Bulan Mei

wando ? bulan apo?
Sia

yang

maantaan Ayah wak

Orientasi personal baik

wando kamari?
Dima rumah wando?

Kampung Laban Kelurahan

Salido Sari Bulan Pesisir
Selatan

Baa
kamari?

kok

wando Awak ado sakik

Discriminative insight
terganggu

Sakik a tu ndo? Lai Patang ko ado langau,

namuah wando carito kumbang, samo uia-uia yang
kan?

tabang-tabang di kapalo den.

Den campak an baliak nyo liak.
(diam cukup lama)

Tu baa lai ndo? Ndak Tapaso lari den kalua rumah lai,
bisa ilang kumbang tu sampai mancabua den ka dalam
doh?

kolam, bia basah baju den

sadonyo. Tu baru namuah pai
kumbang-kumbang tu lai.

Tu baa perasaan wando Sadiah

kini?
Sadiah dek a?
Lah

acok

(Diam saja)
barubek Lah pernah dulu sakali dirawat

kamari ndo?

disiko

Bilo tu ndo?

Kiro-kiro tahun 2011

Dek a dulu awalnyo Ndak ingek wak doh

yang tahun 2011 yang
lalu tu ndo?
Tu bara lamo dirawat Kiro-kiro sabulan lah
disiko dulu tu?
Sasudah tu lai makan Lai.
ubek taratur ndo?
Kama barubeknyo?

Ka RSUD Painan

Tu kini dek a dibawok Awak sakik

kasiko ndo?
Sakik a tu ndo?
Wando

ado

Ndak tau doh.

maraso Ndak ado doh

paniang-paniang,
badabok-dabok
jantuang, atau cameh-

Discriminative Insight
Terganggu

cameh se ndak?
Wando

ado

makai Ndak ado den makai-makai nan

narkoba atau minuman model itu doh. Paliang marokok

kareh bagai?

dennyo

Apo se yang taraso dek Raso ado yang mambisiakwando?

bisiak

Suaro

sia

yang Suaro

mambisiakan?A

padusi.

Disuruahnyo

yang awak mambunuah jo mambaka.

Halusinasi Akustik &

Piromania

dikecekannyo?
Mambaka apo tu ndo?

Mambaka koran samo celana

Baa kok dibaka celana Awak dek danga suaro tu

tu?

ndak

Discriminative
judgement terganggu

sayang

mambaka celana tu?

Bilo

tu

kajadianyo Sahari sabalum kasiko

mambaka-baka tu ndo?
Bara lamo mandanga Sampai tigo hari yang lalu
bisiak-bisiakan

masih ado

manyuruah mambaka tu
ndo?
Kalau mancaliak-caliak Ado dulu sabalum masuak siko
Terdapat Halusinasi
Visual

bayangan hitam gitu lai yang partamo

ado ndo?
Manga

bayangan

tu Dihimpiknyo

ndo?

rasonyo badan.

Ooo..tu

Barek
Halusinasi Taktil

kalau Lai ndak ado doh.

mancium-cium

bau

busuak atau bau harum

padohal ndak ado apoapo doh. Ado ndo?
Wando ado maraso diri Ndak ado doh
wando

wak.

urang

hebat

Halusinasi olfaktori
tidak ada

ndak ndo?
Ado raso-raso curiga ka Ndak ado lo doh
urang-urang lain atau
urang-urang ko rasonyo
jahek se sadonyo ka
wando?
Kalau lalok baa ndo?lai Lai bisa. Tapi acok tajago
Tidur kurang

lamak?

malam.

Dek a tu tajago?

Ndak tau doh. Tajago se

Alah makan tadi ndo?

Alah. Tapi kurang salero.

Nafsu makan menurun

Ooo..Sagitu se dulu yo Iyo.

ndo. Mokasi yo.

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

II. Specific condition

A. Affective
1. Affective condition

: appropriate

2. Emotional

a. Stability

: labil

b. Control

: less

c. Echt/Unecht

: Echt

d. Einfuhlung

: inadequate

e. Deep/shallow

: shallow

f. Differentiation scale

: narrow

g. Emotional flow

: slow

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

C. Sensation and perception abnormalities

a. illusion

: none

b. hallucination
- accoustic

: present

- visual

: present

- olfatoric

: none

- tactile

: present

D. Thought process condition

a.

Speed of thought process

b.

quality of thought :

c.

: Slow

1. clear and sharp

: clear and sharp

2. incoherent

: none

3. Sperrung

: none

4. Hemmung

: Present

5. Flight of ideas

: none

6. verbigeration

: none

7. preservation

: none

Thought condition

1. Central pattern

: none

2. phobia

: none

3. obsession

: none

4. delusion

: none

5. suspicion

: none

6. confabulation

: none

7. repultion

: none

8. inferior feeling

: none

9. Much/little

: little

10. feeling guilty

: present

11. hypochondria

: none

12. others

: none

E. Instingtual drive and behaviour abnormalities

1. abulia

: none

2. stupor

: none

3. raptus/impulsivity

: none

4. excitement state

: none

5. sexual deviation

: none

6. echopraxia

: none

7. vagabondage

: present

8. pyromani

: present

9. mannerism

: none

10. others

: none

F. Overt anxiety

: present, much

G. Reality testing ability

: disturb in behaviour, thinking and feeling

MULTIPLE AXIS RESUME

Axis 1. Clinical Syndrome
Patient often cries, being pensive, and speaks for himself since 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 felt now 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.
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
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

Axis II. Personality Disorder and mental retardation disorder

Personality

: has many friends, pray every day, obedient to his parents

Mental retardation

: none

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 stop of consuming drugs since 1 month ago.
- Break the relationship with his girlfriend
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) could not 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.

Multiple Axis Diagnose

I.

F 33.3 Recurrent depressive disorder current episode severe with psychotic

symptoms

II.

No Diagnose

III.

No Diagnose

IV.

Didnt take medication regularly

V.

GAF 41-50

Differential Diagnose
1. F33.8 Other forms of Recurrent depressive disorder
2. F31.5 Bipolar Affective Disorders current episode severe depressive with
psychotic symptoms
3. F25.1 Schizoaffective disorder Depressive type

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

PROGNOSE
Penilaian

Good

Bad

Onset

Teens

Relaps

Exist

Diagnose

F33. 3 Recurrent

depressive 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

Abstance

Other Disease / Other

Abstence

Disorder

Clinical

: dubia et malam

Functional

: dubia et bonam

Social

: dubia et bonam