Bed Side Teaching
A 27 years old man was admitted to HB Saanin Hospital emergency unit on March 19th 2014. He was accompanied by his family, with chief complaint: the patient was restless, irritable, angry, and hit his father 2 hours before admission. He also confessed that he heard voice telling him to do it. He slept 6 hours per days (more sleep in the afternoon) and eat 3 times per days with one portion of each. Patient was being like that for the second time and had been hospitalized in 2011. The restlessness of the patient is getting lesser after care.Patient identity:
Name / Age:Mr. R / 27 years old
MR:01 17 xxGender:MalePlace and date of birth:Padang, March 25th 2014Marital status:SingleReligion:MuslimOccupation / School: unemployed / not graduated from Electrical Technic Diploma in
Andalas Polytechnic (until 3rd semester)Citizen:IndonesianTribe:MinangkabauAddress:Complex Pesona Inanta E.5, Alai Parak Kopi, PadangA. Internal Status
General appearance: Composmentis
Blood pressure: 110/80 mmHg
Pulse: palpable, regular, 82 times per minute,
Respiration: toracoabdominal, regular, 18 times per minute
Temperature: 36,80C
Body Shape: astenicusHeight: 170 cm
Weight: 50 kg
Cardiovascular system: Inspection: Ictus cordis cant be seen
Palpation: Ictus cordis was palpable, 1 finger medial away from LMCS ICS VPercusion: Cardiac edge : Upper edge ICS II, Right edge LSD, Left edge 1 finger medial from LMCS ICS VAuscultation : Regular rhythm, 82x per minute, no heart murmur.
Respiratory System :
Inspection: Symmetrical 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: Thympanic
Auscultation : Intestinal sound (+) normal
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 examinedMotoric Tonus: Eutonus Coordination: Good
Turgor: Good
Strength: Good
555 555
555 555 Reflex: Physiologic : Patella Reflex (+/+)
Pathologic : Babinski Reflex (-/-)
Sensibility: No abnormality detectedVegetative Function: Good appetite, sleep well
Basic Function: Reading, writing, drawing, and calculating is well done.Specific disorder
Rigid: None
Oculogyric crisis: None Tremor : (+1) Torticollis: None Nasal stiffness: None
Others: NoneAllo AnamnesisName / Age: Mrs.L / 48 years oldGender: FemaleAddress: Complex Pesona Inanta E.5, Alai Parak Kopi, Padang
Phone number: 0852113327xxOccupation: Elementary school teacherEducation: Bachelors degreeRelationship: MotherI. Primary cause of hospitalization :
The patient was restless, irritable, angry, and hit his father 2 hours before admission. He also confessed that he heard voice telling him to do it. He slept 6 hours per days (more sleep in the afternoon) and eat 3 times per days with one portion of each. Patient was being like that for the second time and had been hospitalized in 2011. The restlessness of the patient is getting lesser after care.Patients complaint today: None
II. History of illness :
2008-2009 (the month was not remembered)The patient didnt continue his study since 2008 because he couldnt handle his tasks in college and had GPA (Grade Point Average) less than 2. He stopped in 3rd semester but he still took money from his parents for the next semester college payment. He spent the money for servicing his motorcycle and gave it to orphanages. His parent was angry when they knew about the fact, especially his father who always pushes him hard to study well and be successful person since he is a oldest child and the only one son in his family. Then, his parent never care anymore about what he was doing, but his mother still gave him money.One day he went to his hometown, Payakumbuh and got an accident. According to medical examination there was no serious injury, but after the accident he looked very shock, he didnt talk a word, couldnt sleep, and didnt want to eat. He can move his body spontaneously without a clear cause. He went to neurologist and got medicines, but according to the family, after some days there wasnt improvement of his condition and he became strange. He started to be irritable, easy to be angry, and like to kiss his mother. He also heard womans voice telling him to do things. Then the family took him to psychiatrist and got medicines.
Because the family couldnt see improvement of his condition, after 8 months consuming drugs from psychiatrist, they went for alternative treatment in their hometown that has boarding system. After some weeks, he was getting worse and the family decided took him home. after some weeks, slowly, he got better and can walk normally. 2011 (the month was not remembered)His father had a stroke attack, so he went to the hospital to see his father. In hospital, he hit his brother in law without reason so his family took him home. But he continued to be angry without reason and he wrecked household appliances. So his family took him to HB Saanin Hospital and he got hospitalized for a month. He went home with a quite condition. He controls his condition regularly and took medicine obediently. The medicines are:
Risperidone 2x1 tab @ 2 mg
Haloperidol 2x1 tab @ 1,5 mg
CPZ 1x1 tab @100 mg (his mother only gave CPZ when he started to talked
irrationally)THP 2x1 tab @ 2 mgAfter come home, he still doesnt have any job, he just spent the time at home, or went to his hometown or his friends home.
2014 (March)
He drank his father water and his father scolded him, but suddenly he became angry and hit his father. His father wanted to attack back, but other families tried to stop them. His father forced his mother to take him back to the hospital. Then his family brought him to the HB Saanin Hospital and he got hospitalized. His mother confessed that he drank a cup of coffee in the morning of that day outside her supervision.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. He likes to play with friends.Teenage: growth and development according to his age. He likes to play with friends.
He was a very religious teenager and he liked to give a speech in the mosque.Adolescence: unemployed, still had a good relationship with his friends at schools and college.
Educational backgroundSD
: SD N 03 Alai Padang, graduated in 6 yearsSMP
: MTsN 1 Padang, graduated in 3 years
SMA
: SMKN 2 Padang, graduated in 3 years
College: Electrical Technic Diploma in Polytechnic Andalas Padang, not graduated. He didnt continue his study because he couldnt handle the tasks and GPA < 2. He
stopped in 3rd semesterIII. Occupation History
Unemployed IV. Marital History
Single V. Social Economic history
She lived with his father, mother, and 3 sisters 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.
IncomeFathers salary
Rp. 2.500.000,-
Mothers salary
Rp. 2.500.000,Sisters allocation
Rp. 1.000.000,-+
Rp.6.000.000,-
OutcomeFamily cost
Rp. 4.000.000,-
Water cost
Rp. 70.000,-
Electricity cost
Rp. 80.000,-+
Rp. 4.150.000,-
Remaining cost Rp. 1.850.000,-VI. Family history of illnessThere were no family members that has same symptoms like this or has mental disorder.
Graphic of illness
Autoanamnesis, March 21th 2014:QuestionsAnswersInterpretation
Assalamualaikum bang RobbiWaalaikum salamComposmentis
Cooperative
Bang, ambo Lani dokter muda disioko, buliah awak carito-carito jo abang kini bang?Buliah...
Lah bara umua abang bang?27Good time orientation
Tahun bara tu berarti bang?1987
Tanggal bara tu bang?25 Maret 1987
Oo
Lah bara hari disiko bang?Lah 4 hari
Sia yang baok kamari bang?KeluargaGood personal orientation
Sia se tu bang?Mama papa om adiak-adiak.
Lansuang di baok kamari abang?Ndak ka IGD di muko dulu. Hari ko baru ka Flamboyan ko.Good place orientation
Baa caritonyo bang, kok dibaok abang kamari samo keluarga?(senyum lebar, kontak mata ada, tapi tidak menjawab)Hemmung
Bang? Baa bang? Baa kok dibaok kamari?Bacakak samo papa
Bacakak? Baa caritonyo tu bang(lama menjawab)
Manga abang waktu tu?Ndak nio makan
Jam bara memangnyo kejadiannyo bang?Maghrib
Alun makan siang abang lai do?(tertawa) alun
Tu baa lai bang?(tersenyum senang)
Bang? Iyo tu berang papa,bangih se caliaknyo.
Tu kanai berang abang?Mama nelfon omLack of attention
Manga nelfon om bang?Baok abang ka rumah sakik
Itu se nyo bang? Abang ndak ado berang ka papa?NdakConfabulation
Iyo bana tu bang? Tu manga abang dek itu se di baok ka rumah sakik?Iyo. Dek bacakak.Disturbed discriminative insight
Bacakak baa ko bang?Papa berang
Abang berang lo?Ndak
Bacakak muluik?Iyo
Bacakak muluik se nyo bang? Iyo
Yang lain? (tertawa)
Ado abang kayak malokok papa abang gai nak?Ndak
Papa abang ado malokok abang?Iyo
Tu diam se abang?Iyo
Jadi baa kok abang yang di baok ka rumah sakik?DisuntikDisturbed discriminative judgement
Supayo disuntik?Iyo
Papa abang ndak disuntik? Abang yang disuntik?
Abang tu yang salah?(tertawa)
Baa kok abang yng disuntik?.(tertawa)
Baa bang?Abang sakik.
Abang alah duo kali disiko ma. Di Flamboyan ko.Lack of memory
Iyo bang? Bilo yang pertamo?Tahun 2011
Manga waktu tu tu bang, kok dirawat abang?(tertawa)
Ndak takana
Kan baru tu bang kana-kana lah dulu bang(tertawa)
Baa caritonyo waktu tu tu bang?(tidak menjawab)
Kini apo yang taraso bang?(tersenyum lebar)Inappropriate affect
Lai sanang disiko bang? Sanang hati abang bantuaknyo ha.Indak (tapi tersenyum senang)
Lai banyak kawan disiko?Indak (masih tersenyum senang)
Waktu sakik tu baa rasonyo bang?(tertawa)
Ndak tau
Berang bana abang rasonyo?(tertawa)
Ndak tau
Kalau sadang sakik ko lai abang tadanga suaro-suaro bang?AdoAuditoric halutination
Suaro apo tu bang?Nyo mangecek ka abang. Suaro apo tu?
Baa suaronyo bang? Suaro abang?Ndak suaro padusi
Mangeceknyo ka abangIyo.
Lai sabana tu bang? Ka abang se nyo mangecek nyo bang?Yo bana.
Ndak tau
Apo yang nyo kicek an emangnyo bang?Karajoanlah karajoanlahDelusion of influence
Tu abang karajoan?Indak lah
Nampak urang nyo bang?
Atau ado Nampak bayang-bayang?Ndak
Mencium bau-bau aneh bang?Ndak ado
Atau ado nyo kaca-kaca abang?Ndak
Haa tu nyo ha.Auditoric halutination
Apo tu bang?Ado tadanga?
Ndak bang apo katonyo bang?indak
indak katonyo bang/Iyo. Ndak tadanga?
Ndak bang. Ndak ado apo-apo do. Sabana tu bang?Iyo. Ndak tadanga do yo?
Ndak ado tadanga do bang.(tersenyum senang)
Ado yang taraso baulang jadinyo di kapalo abang yang dikecekan tu bang?Iyo. Baulang-ulang rasonyo di kapalo ko.Thought eco
Bagema rasonyo?Iyo
Kalau pikiran abang dibaco urang lain rasonyo ado bang?Ndak
Atau abang bisa mambaco pikiran urang?Ndak
Jadi kini apo yang taraso bang?(mengangkat bahu)
Ndak tau
(senyum-senyum)Inappropriate affect
Ndak nio pulang do?Nio sobok papa
Baa tu?Jalan-jalan
Kama jalan-jalan bang?Ka pantai
Ka kampuang abangIncoherent
Kampuang abang di pariaman?Di payakumbuah
Kalau kalua dari siko apo rencana bang?(tertawa)
Lah karajo abang?Alah
Dima bang?Di PLNDelusion of grandeur
Apo tu bang karajonyo?Listrik. Masang instalasi lisrik rumah-rumah ko ha
Oo lah lamo abang karajo disitu?Alah. Lah 3 tahun.
Tapi abang sakik tahun 2011., masih karajo disitu? Iyo. Tahunan.
Tamat apo abang dulu bang?SMTI
Sekolah Menengah Teknik Industri?Iyo
Tamat 3 tahun bang?Iyo
Sudah tu langsuang karajo?Ndak kuliah dulu
Oo dima kuliah bang?Di poli
Politeknik Unand?Iyo
Jurusan apo bang?Sastra
Ha. Ma ado jurusan sastra bang?Ado
Tapi abang dari SMTI. Ambiak sastra abang?Iyo
Sastra apo bang? Sastrawan
Ma ado jurusan sastrawan bangAdo
Yang ado tu sastra Indonesia, sastra InggrisIndonesia
Sastrawan Indonesia
Bara tahun tu bang?D4
Iyo, bara tahun tu bang?4 tahun
Sudah tu karajo abang di PLN?Iyo
Bisa yo bang? Abang tapi sastrawan?Bisa. Awak sewo.
Sewo ko baa bang?Tahunan di sewo.
Pulang dari siko abang nio karajo baliak disinan?Iyo
Abang bilo rencana pulang emangnyo?Ndak tau
(tersenyum)Inappropriate affect
Sakik apo abang kini ko?Ndak tau
Makan ubek abang?Iyo. Makan ubek taruih.
Untuak apo tu bang makan ubek?(tertawa)
Jadi abang ndak nio pulang?Di rawat dulu
Baa kok abang dirawat?Supayo sehat
Bara lamo abang ka dirawat?Sabulan
Sabulan? Ndak nio pulang abang?Ndak baa bia sehat dulu.
Jadi apo sakik abang kini ko?(senyum-senyum)
Kini ndak ado yang taraso? Sedih? Sanang? Ndak ado (tersenyum lebar)
Yo lah mokasi yo bang. Istirahatlah abang lai.
AssalamualaikumWaalaikum salam.
Explanation and Conclusion of Psychiatric ExaminationExamination was done on March 21st, 6.00 p.m.1. General appearance
Consciousness/sensorial:composmentis/good
Attitude:cooperative
Motoric:active
Facial expression:richVerbalization:speak clearlyPsychical contact:could be done / proper enough / long enough
Attention:good enoughInitiative:good enoughPatientss writing and drawing is present.
2. Specific condition
A. Affective
1. Affective condition : inappropriate2. Emotional :
a. Stability:stable
b. Control:goodc. Echt/unecht:echt
d. Einfuhlung:inadequate e. Deep/shallow:shallowf. Differentiation scale:narrow
g. Emotional flow:fastB. Intellectual condition of function
a. Memory:lessb. Concentration:difficultc. Orientation:time, personal, and place orientations are goodd. General knowledge : hard to predicte. Intelligence prediction:average
f. Discriminative insight:disturbedg. Discriminative judgment:disturbedh. Intellectual decreasing: noneC. Sensation and perception abnormalities
1. Illusion: none
2. Hallucination:
Acoustic:present, the sound of a woman telling him to do thingsVisual:noneOlfactory: none Tactile: none
Gustatory: noneD. Thought process condition
1. Speed of thought processs:slow2. Quality of thought process:
a. Clearness and sharpness:not clear enough and not sharp enough
b. Circumstantial:nonec. Incoherent:noned. Sperrung:none
e. Hemmung:presentf. Flight of ideas:none
g. Verbigeration:none
h. Preservation:none
3. Thought condition
a. Central pattern:noneb. Phobia:none
c. Obsession:noned. Suspicion:nonee. Delusion:delusion of influence, delusion of
grandeurf. Confabulation:presentg. Dominance, animosity:none
h. Inferior feeling:nonei. Much / little:littlej. Guilty feeling:nonek. Hypochondria:none
l. Others:none
E. Instinctual impulse and behavior abnormalities
a. Abulia:presentb. Stupor:none
c. Raptus/impulsivity:presented in 3 days ago, subsided since a
day agod. Excitement state:nonee. Sexual deviation:none
f. Echopraxia:none
g. Vagabondage:noneh. Pyromania:nonei. Mannerism: none
j. Others:noneF. Over anxiety:noneG. Reality testing ability:behavior, thought, feeling are disturbedmultiple axis Resume
Axis I. Clinical SyndromeThe patient was restless, irritable, angry, and hit his father 2 hours before admission. He also confessed that he heard voice telling him to do it. He slept 6 hours per days (more sleep in the afternoon) and eat 3 times per days with one portion of each. Patient was being like that for the second time and had been hospitalized in 2011. The restlessness of the patient is getting lesser after care.
General Appeareance: composmentis cooperative, good sensorium, initiative (-), cooperative, active motoric, rich facial expression, lack of initiative, lack of attention, talk clearly, physical contact can be done, proper enough and long enough.Specific condition:
a. Affective condition: inappropriate, stable, control is good, echt, inadequat, shallow, narrow, fast.b. Intellectual condition and function: memory is less, concentration is difficult, discriminative insight disturbed, discriminative judgment is disturbed, orientation is good, intelligence prediction is averagec. Sensation and perception abnormalities: accoustic halutination d. Thought process condition: slow, not clear and not sharp enough, incoherent, hemmung, delusion of influence, delusion of grandeur, confabulatione. Instinctual drive and behavior abnormalities: abulia, raptus/impulsivity presented in 3 days ago, subsided since a day agof. Overt anxiety: noneg. Reality testing ability: behavior, feeling and thinking are disturbedAxis II : Personality Disorder and Mental Retardation Disorders
Personality: outgoing, has friendsMental retardation: noneAxis III : General Medical Condition
Head traumas history was absent No history of malaria, typhoid, or brain and neurological diseaseAxis IV : Phsychosocial Stressor and Environment His father always pushes him hard to study well and be a successful person and his father also easy to be angry to him
He couldnt continue his study because he couldnt handle tasks and his GPA < 2
Being jobless since he stopped to study
Axis V: Global Assessment of Function
Daily activity couldnt be done since 3 days ago Social relationship couldnt be done since 3 days ago Spending time with watching TV, recreation, couldnt be done since 3 days agoMULTIPLE AXIS DIAGNOSIS
I. F 25.0 Schizoaffective disorder, manic typeII. No diagnosisIII. No diagnosisIV. Being pushed hard and rudely by his father, he couldnt continue his study and being joblessV. GAF 51-60DIFFERENTIAL DIAGNOSISI. F 20.1 Schizophrenia hebephrenicII. F 31.2 Bipolar affective disorder,current episode manic with psychotic symptomsIII. F 20.3 Undifferentiated schizophreniaTHERAPY Risperidon 2 x 2 mg Diazepam 1 x 2 mgSUGGESTION FOR THERAPY
CPZ 2 x 100 mg For long term therapy: Injection of Haldol decanoas 50 mg IM, once a month. Psychotherapy to the patient and family.PROGNOSIS
PointGoodNot good
OnsetAdult
DiagnosisSchizoaffective disorder, manic type
Family SupportNot good enough
Marital statusSingle
EconomicMiddle higher class
MedicineRegularly
Faktor pencetusClear
GeneticNone
Others diseaseNone
Clinical:dubia at malamFunctional:dubia at malamSocial:dubia at bonamStopped his study
His parents were angry
His father irritate his feeling
His father got a stroke attack
(3) 2014
2011
2008-2009
12