Episode of Major Depression with Psychotic Symptoms

DM RS EKA PUTRA DM HASRA MUKHLISAN

 Bed Side Teaching A female patient aged 35 years, came to GMO Polyclinic Prof. RSJ. HB Saanin Padang on 8 November 2013 at 9:30 am, the complaints would like to add drugs prescription.Pasien treatment for the second time with complaints can not sleep, crying, eating less, often suspicious of others, feel inferior, and the silence in the room . Ever seen a black shadow which whispered something into his ear. Patients experiencing this since 1.5 months ago when her husband were caught cheating with another woman.

Patient identity: Name / Age : Mrs. Y / 35 years old MR : 01.25.xx Gender : Female Place and date of birth : Padang, Juli 5th 1977 Marital status : Married, with 4 children Religion : Muslim Occupation/School : housewife/ graduated from junior high school Citizen : Indonesian Tribe : Minangnese Address : Jalan Djuanda No 36, Lubuk Begalung Padang

Internal Status General appearance : Compos Mentis Blood pressure : 110/80 mmHg Pulse : easily palpable, regular, 80x per minute, Respiration : torakoabdominal pattern, regular, 19x per minute Temperature : 36,40C Body Shape : astenikus Height : 161 cm Weight : 64 kg

 Cardiovascular system : Inspection : Ictus cordis was not seen Palpation : Ictus cordis was palpable, 1 finger medial from LMCS ICS V Percusion : Cardiac edge : Upper edge ICS II, Right edge LSD, Left edge 1 finger medial from LMCS ICS V Auscultation : Regular rhythm, 80x per minute, no heart murmur.

 Respiratory System : Inspection : Symmetrical, left = right in static and dynamic position Palpation : Fremitus left = right Percusion : Sonor on left and right Auscultation : Vesicular, no ronkhi (-/-), no wheezing (-/-)

 Gastrointestinal system : Inspection : Not distended Palpation : Liver and spleen were not palpable Percussion : Thympani Auscultation : intestinal sound (+) normal Specific disorder : No abnormality detected

 Neurological Status Cranial Nervous (five senses) : Vision, smelling, hearing, tasting, and tactil are well Meningeal Signs : None High Intracranial Pressure Signs : None Eyes Movement : Free to all direction Perception : No nystagmus, no diplopia Pupil : Round and isokor Light Reflex : +/+ Convergence Reaction : Not examined Corneal reflex : Not examined Ophtalmoscopic examination : Not examined

Motoric Tonus : Eutonus, Coordination : Good Turgor : Good Strength : Good 555 555 555 555 Reflex : Physiologic KPR (+/+), Pathologic Babinsky (-/-) Sensibility : No abnormality detected Vegetative Function : Good appetite, sleep well

 Basic Function : Reading, writing, drawing, and calculating is well done. Specific disorder Rigid : None Occulogirik crisis : None Tremor : None Torticolis : None Nasal stiffness : None Others : None

 Autoanamnesa

 Primary cause of hospitalization : none. Patients complaint now : Patient would like to add drugs prescription. She treatment for the second time with complaints can not sleep, crying, eating less, often suspicious of others, feel inferior, and the silence in the room . Ever seen a black shadow which whispered something into his ear. Patient experiencing this since 1.5 months ago when her husband were caught cheating with another woman.

 History of illness : September 2013 Can not sleep, crying, eating less, often suspicious of others, feel inferior, and the silence in the room, saw a black shadow whispered something into his ear. Previous patient husband caught having an affair with another woman. The patient had never been treated for mental illness before this incident. Premorbid history Infant : born spontaneously, birth was assisted by midwife, no history of jaundice, cyanosis, and seizure. Childhood : growth and development according to his age. Teenage : growth and development according to his age. Adolescence : had a lot of friends

Educational background SD : SD N 15 Padang, until sixth grade SMP : SMP N 25 Padang, until third grade Occupation History Patient is a housewife Marital History Patient was married 1 time, in 1992 Social Economic history She lived with her children in a semi permanent house. There is electricity there. The water source is from the well. Monthly income is enough for the patient.

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

EXPLANATION AND CONCLUSION OF PSYCHIATRIC EXAMINATION Examination is on November 8th 2013, 9.30 WIB General appearance Consciousness/sensorial : compos mentis/good Attitude : cooperative Motoric : active Facial expression: rich Verbalization : speak clearly Psychic contact: could be done / appropriate / long enough Attention : good enough Initiative : good enough Writing and drawing is present.

Specific condition Affective Affective condition : normotim Emotional : Stability : stable Control : good enough Echt/unecht : echt Einfuhlung : adequat Deep/shallow : deep Differentiation scale : narrow Emotional flow : fast

Intellectual condition of function Memory : good enough Concentration : good enough Orientation : good enough General and schooling knowledge : hard to predict Discriminative insight: good enough Intelligence prediction : average Discriminative judgment : good enough Intelectual deterioration : none

Sensation and perception abnormalities Illusion : none Hallucination : Acoustic : present, the sound of people asking her, since 1.5 months ago, was reduced from 4 weeks ago Visual : present, big tall black shadow, since 1.5 months ago, was reduced from 4 weeks ago Olfactory : none Tactile : none Gustatory: none

Thought process condition Speed of thought processs Quality of thought process: Clear and sharp : Circumstantial : Incoherent : none Sperrung : none Hemmung : none Flight of ideas : Verbigeration : Preservation : none

fast

clear enough and sharp enough none

none none

Thought condition Central pattern Phobia : Obsession : Delusion : Suspicion : weeks ago Confabulation : Repulsion : Inferior feeling from 4 weeks ago Much/little : Feeling guilty : Hypochondria : Others :

: none none none none yes, since 1.5 months ago, was reduced from 4 none none : much none none none

yes, since 1.5 months ago, was reduced

Instinctual drive and behavior abnormalities Abulia : none Stupor : none Raptus/impulsivity : none Excitement state : none Sexual deviation : none Echopraxia : none Vagabondage : none Pyromania : none Mannerism : none Others : none Over anxiety : present, little Reality testing ability : not present

 MULTIPLE AXIS RESUME Axis I. Clinical Syndrome Patient would like to add drugs prescription. She treatment for the second time with complaints can not sleep, crying, eating less, often suspicious of others, feel inferior, and the silence in the room . Ever seen a black shadow which whispered something into his ear. Patient experiencing this since 1.5 months ago when her husband were caught cheating with another woman. General Appeareance: composmentis cooperative, good sensorium, good attention, initiative (+), cooperative, active motoric, rich facial expression, clear talk, physical contact appropriate and long.

 Specific condition: Affective condition: normotim, stable, control is good enough, echt, adequat, deep, narrow, fast Intellectual condition and function: Memory is good enough, Concentration is good enough, Discriminative insight is good, Discriminative judgment is good, orientation is good Sensation and perception abnormalities: accoustic halutination (+), visual halutination (+) Thought process condition: fast, clear and sharp, suspicious since 1.5 months ago, was reduced from 4 weeks ago, much Instinctual drive and behavior abnormalities: Abulia none, excitement state not present, vagabondage not presents, pyromani not presents. Overt anxiety: present, little Reality testing ability, disturbed: not present

Axis II : Personality Disorder and Mental Retardation Disorders Personality: outgoing, has a lot of friend 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 Pshychosocial : husband were caught cheating with another woman Axis V: Global Assessment of Function - Social relations (visiting friends, attending community events) has been able to do since 4 weeks ago. - Daily work (cooking, washing, cleaning the house) is not compromised. - Charge time (watching TV, sports, reading) has been able to do since 4 weeks ago.

 MULTIPLE AXIS DIAGNOSIS F 32.3 Episode of Major Depression with Psychotic Symptoms. No Diagnosis. No Diagnosis husband were caught cheating with another woman GAF 51-60

 DIFFERENTIAL DIAGNOSIS F 41.1 Comprehensive Anxiety Disorders F 43.2 Adjustment Disorders THERAPY - Risperidon 2 x 2 mg - Diazepam 2 x 5 mg - Antiprestin 1 x 20 mg PROGNOSIS Clinical : dubia at bonam Functional : dubia at bonam Social : dubia at bonam