Bed Side Teaching

A female patient aged years, came to Psychiatric Polyclinic Prof HB Saanin in Padang
on 13 April 2016 at 17:00 pm, with complaint would like to check the healthy of . Patient have
been control regularly to Psychiatric Polyclinic Dr.M.Djamil Hospital since 2009. Present
complaints still felt by patient are feeling sad, easily exhausted, pessimistic view of the future,
decreased self esteem. She sleep 8 hours per days and eat 3 times per days with one portion
of each. Patients experiencing this since 8 years ago when her husband were married with
another woman.
th

Patient identity:
Name / Age

Mrs. Y / 50 years old

MR

Gender

Female

Place and date of birth

Padang, January 1st 1964

Marital status

Married

Religion

Muslim

Occupation / School

self-employed /not graduated from Elementary School (until 5th

grade )

Citizen

Indonesian

Tribe

Minangkabau

Address

Jl. Dr. Sutomo Belakang SLB, Padang

A. Internal Status
General appearance
Blood pressure
Pulse
Respiration
Temperature
Body Shape
Height
Weight
Cardiovascular system

: Composmentis
: 120/70 mmHg
: palpable, regular, 83 times per minute,
: toracoabdominal, regular, 18 times per minute
: 36,50C
: astenicus
: 160 cm
: 75 kg
: were not examined

Respiratory System : were not examined

Gastrointestinal system : were not examined
1

Specific disorder : No abnormality detected

B. Neurological Status
Cranial Nervous (five senses) : Vision, smelling, hearing, tasting, and tactile are well
Meningeal Signs
: None
High Intracranial Pressure Signs : None
Eyes
- Movement
: Free to all direction
- Perception
: No nystagmus, no diplopia
- Pupil
: Round, isochoric
- Light Reflex
: +/+
- Convergence Reaction
: Not examined
- Corneal reflex
: Not examined
- Ophthalmoscopy examination
: Not examined
Motoric
- Tonus
- Coordination
- Turgor
- Strength

Sensibility
Vegetative Function
Basic Function

: Eutonus
: Good
: Good
: Good
555 555
555 555
: Physiologic : Patella Reflex (+/+)
Pathologic : Babinski Reflex (-/-)
: No abnormality detected
: Good appetite, sleep well
: Reading, writing, drawing, and calculating is well done.

Specific disorder
- Rigid
- Oculogyric crisis
- Tremor
- Torticollis
- Nasal stiffness
- Others

: None
: None
: None
: None
: None
: None

Reflex

Allo Anamnesis
Name / Age
Gender

: Dodi
: Male

Address

:-

Phone number

:-

Occupation

:-

Education

:-

Relationship

: Son of patient
2

I.

History of illness :
2006 (the month was not remembered)
Her husband was married with another woman but they werent divorced. Itu

keinginan suaminya dan tidak diketahui sebab yang jelas. It was on her husband own
decision and the reason doing this wasnt be explained by him. In this time, patient started
complaints feeling sad, lost her interest, sleep dificulty and woke up in the middle of night
frequently, felt dissapointed, frequent crying.

2009 (the month was not remembered)

Patient worked as Cleaning Service at Klinik Bidan Cici. When she worked, she
often get blamed because her boss thought her work was not clean although the patient
thought her work was clean enough. Patient became upset and felt more sad. Patient often
thought about her husband married with another woman and didnt get money for herself
and her children living. Then her husband brought her to psychiatric private practice
because her complaints. The Psychiatrist suggested her to go to Psychiatric Polyclinic Dr.
M.Djamil Hospital. She controlled regularly and since then, patient regularly consumed the
medicine given and felt her complaints was decreased.
2010 (the month was not remembered)
Her husband married again with another woman without divorced her and his
second wife. Patient felt more sad and disappointed but still consumed the medicine
regularly.
2014 (1st September)
3

She came to Psychiatric Policlinic Dr. M. Djamil Hospital to add drugs prescription.
From interview with the patient, she told about her son plan entering the college or The
Police Academy. She afraid about her financial for her son to continue his study. Present
complaints still felt by patient are feeling sad, easily exhausted, pessimistic view of the
future, decreased self esteem.
Premorbid history
Infant
: born spontaneously, birth was assisted by dukun beranak, no history of
jaundice, cyanosis, and seizure.
Childhood
: growth and development according to his age. She likes to play with friends.
Teenage
: growth and development according to his age. She likes to play with friends.
Adolescence : self-employed, still had a good relationship with the others.

Educational background
SD
: SD N Sungai Limau, not graduated (until 5th grade)
II.

Occupation History
Self-employed

III.

Marital History
Married

IV.

Social Economic history

She lived with her two children in a permanent house. There is electricity and the water

source is from PDAM. Monthly income of the family is more than enough for the patient.
Income
Patients salary

Rp. 0

Outcome
Family cost

Rp. 2.500.000,-

Water cost

Rp.

70.000,-

Electricity cost

Rp.

100.000,-+

Rp. 2.670.000,Remaining cost Rp. 330.000,4

V.
Family history of illness
There were no family members that has same symptoms like this or has mental disorder.

Graphic of illness
Her husband married with
anothe woman

2006

She get blamed by

her boss

2009

Her husband married

with another woman
again

2010

Her son want to enter

college

2014

Autoanamnesis, September 1st 2014:

Questions

Answers

Interpretatio
n

Assalamualaikum

bu Waalaikum salam

Yurnalis
Buk, ambo Nia, dokter muda Buliah...

Composmentis
Cooperative

disiko, buliah awak tanyotanyo saketek buk?

Lah bara umua buk?
Tahun bara tu berarti buk?
Tanggal bara tu buk?
Ibuk tau kini sedang dima ?

1964
1 Januari 1964
Di Padang, RSJ Prof HB

Hari apo kini buk ?

Jo sia ibuk kamari?

saanin
Selasa
Rami-rami duo oto

Good time
orientation

Good personal
orientation
Not good

Dima rumah ibuk?

place
orientation

Baa kok ibuk kamari?

Dibaok keluarga
Ado ibuk berang-berang di Ndak ado do
rumah ?
Ado ibuk pai jalan-jalan Lai, pai jalan jalan suko.
kalua rumah ?

Kadang ka rumah tetangga,

rumah mintuo
Sejak bilo ibuk suko pakai Iyo suko se.
asesoris tu ?
Suko ibuk pakai warna baju Iyo ancak

Manik
Manik

yang merah, ungu, bermotif

rami ko buk ?
Lah acok barubek kamari Baru sakali ko
buk?
Ibuk bisa maubek urang yo Iyo ibuk maubekan urang bisa.

Waham

katonyo ?

kebesaran

Jo aia putiah, ibu bacoan se tu

cegak urang mah

Ibuk dari ma tadi sabalum Dari Langik
6

kamari?
Ibuk dari

langik

manga Ibuk tadi sobok jo kawan-

tadi ?

kawan ibuk di ateh langik trus

Lalok ibu baa?

ibuk sobok jo tuhan jo

Lalok susah, acok tasentak

malam-malam
Kini baa perasaan ibu? Apo Ndak ado taraso apo-apo do.
yang taraso kini bu?
Yang lain apo nan ibuk Iyo, itu se nyo
rasoan?
Kalau
itu,
mandanga

ado

ibuk Ado. Bisikan dari nabi untuk

bisiak-bisiakan bersedekah dan sholat

buk?padohal

ndak

urangnyo buk?
Ooo...kalau

Halusinasi

ado

auditorik (+)

mancaliak- Hantu ndak ado do. Malaikat

caliak hantu, malaikat gitu samo nabi Muhammad ado. Halusinasi

ado buk?
Mancium

Acok

nampak

di

taman visual (+)

walikota Bukittinggi
bau-bauan?bau Ndak ado doh

harum atau bau busuak, tapi

ndak ado sabananyo doh
Ado
ibu
cameh-cameh Ndak ado doh
balabiahan?

Halusination

Berdebar-

Halusinasi
olfaktorik (-)

No anxiety

No Anxiety

debar?
Ado ibuk maraso sadiah Ndak ado do
akhir-akhir ko ?
Ado ibuk maraso bersalah ? Ndak ado do
Ado ibuk bapikia kalau Ndak ado do

No depression

iduik ibuk ndak baguno lai ?

Ibuk ado pakai obat-obatan Ado ubek patang yang diagiah
buk ?
dokter
Sakik yang lain ado buk?, Ndak ado doh
sakik kapalo?paruik sakik?
Iyo lah buk, tarimo kasih Iyo samo samo nak
banyak yo buk
7

Explanation and Conclusion of Psychiatric Examination

Examination was done on 11st April 2016, 17:00 p.m
1. General appearance
Consciousness/sensorial
Attitude
Motoric
Facial expression
Verbalization
Psychical contact
Attention
Initiative

:
:
:
:
:
:
:
:

composmentis/good
cooperative
active
rich
speak clearly
could be done / proper enough / long enough
good enough
good enough

2. Specific condition
A. Affective
1. Affective condition
2. Emotional :
a. Stability
b. Control
c. Echt/unecht
d. Einfuhlung
e. Deep/shallow
f. Differentiation scale
g. Emotional flow

B. Intellectual condition of function

a. Memory
b. Concentration
c. Orientation
d.
e.
f.
g.
h.

General knowledge
Intelligence prediction
Discriminative insight
Discriminative judgment
Intellectual decreasing

eutim
:
:
:
:
:
:
:

stable
good
echt
adequate
deep
wide
fast

:
:
:

good enough
good enough
personal, and place orientations are good.

:
:
:
:
:

Time is not good

hard to predict
average
good enough
good enough
none

C. Sensation and perception abnormalities

1. Illusion
: none
2. Hallucination
:
Acoustic
: yes
Visual
: yes
Olfactory
: none
Tactile
: none
Gustatory
: none
D. Thought process condition
8

1. Speed of thought processs

2. Quality of thought process:
a. Clearness and sharpness
b. Circumstantial
c. Incoherent
d. Sperrung
e. Hemmung
f. Flight of ideas
g. Verbigeration
h. Preservation

3. Thought condition
a. Central pattern
b. Phobia
c. Obsession
d. Suspicion
e. Delusion
f. Confabulation
g. Dominance, animosity
h. Inferior feeling
i. Much / little
j. Guilty feeling
k. Hypochondria
l. Others

fast

:
:
:
:
:
:
:
:

clear enough and sharp enough

none
none
none
none
none
none
none

:
:
:
:
:
:
:
:
:
:
:
:

none
none
none
none
none
none
none
present
much
none
none
none

E. Instinctual impulse and behavior abnormalities

a. Abulia
:
none
b. Stupor
:
none
c. Raptus/impulsivity
:
none
d. Excitement state
:
none
e. Sexual deviation
:
none
f. Echopraxia
:
none
g. Vagabondage
:
none
h. Pyromania
:
none
i. Mannerism
:
none
j. Others
:
none
F. Over anxiety

none

G. Reality testing ability

behavior,

thought,

feeling

are

not

disturbed

MULTIPLE AXIS RESUME

Axis I. Clinical Syndrome
Patient complaints still feeling sad, easily exhausted, pessimistic view of the future,
decreased self esteem. She sleep 8 hours per days and eat 3 times per days with one portion
of each. Patients experiencing this since 8 years ago when her husband were married with
another woman.
General Appeareance: composmentis cooperative, good sensorium, initiative (+),
cooperative, active motoric, rich facial expression, talk clearly, physical contact can be
done, proper enough and long enough.
Specific condition:
a. Affective condition: eutim, stable, control is good, echt, adequate, deep, wide, fast.
b. Intellectual condition and function: memory is good enough, concentration is good
enough, discriminative insight is not disturbed, discriminative judgment is not
disturbed, orientation is good, intelligence prediction is average
c. Sensation and perception abnormalities: none
d. Thought process condition: fast, clear and sharp enough, inferior feeling
e. Instinctual drive and behavior abnormalities: none
f. Overt anxiety: none
g. Reality testing ability: behavior, feeling and thinking are not disturbed
Axis II : Personality Disorder and Mental Retardation Disorders
Personality: outgoing, has friends
Mental retardation: none
Axis III : General Medical Condition

Head traumas history was absent

No history of malaria, typhoid, or brain and neurological disease

Axis IV : Phsychosocial Stressor and Environment

Her husband married again for the first time on 2006 and for the second time on 2010
10

 She is afraid not be able to pay for her son study

Axis V: Global Assessment of Function
Daily activity could be done
Social relationship could be done
Spending time with watching TV, recreation, could be done

MULTIPLE AXIS DIAGNOSIS

I.

F 32.0 Mild Depressive episode

II.

No diagnosis

III.

No diagnosis

IV.

Her husband married again for the first time on 2006 and for the second time on
2010
She is afraid not be able to pay for her son study

V.

GAF 80 71

DIFFERENTIAL DIAGNOSIS
I.

F 33.0 Recurrent Depressive Disorder with mild present episode

II.

F 32.8 Another Depressive Episode

III.

F 38.10 Recurrent Brief Depressive Disorder

THERAPY

Tilsan 1 x 25 mg

Valdimex 1 x 0,5

Haloperidol 1 x 1,5 mg

Anxibloc 2 x 1

SUGGESTION FOR THERAPY

Psychotherapy to the patient and family.

PROGNOSIS
11

Onset
Diagnosis

Point
Adult
Mild

Family Support
Marital status
Economic
Medicine
Precipitating factor
Genetic
Others disease

episode
good enough
Married
Lower Middle class
Regularly
Clear
None
None

Clinical

dubia at bonam

Functional

dubia at bonam

Social

dubia at bonam

Good

Depressive

Not good

12