Bed Side Teaching

A female patient aged 50 years, came to Psychiatric Polyclinic Dr.M.Djamil Hospital in

Padang on 1st September 2014 at 11:30 am, with complaint would like to add drugs prescription.
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.

Patient identity:
Name / Age

Mrs. Y / 50 years old

MR

02 78 29

Gender

Female

Place and date of birth

Padang, January 1st 1964

Marital status

Married

Religion

Muslim

Occupation / School

self-employed (making and selling cakes)/ 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
: 130/90 mmHg
: palpable, regular, 86 times per minute,
: toracoabdominal, regular, 18 times per minute
: 36,80C
: astenicus
: 155 cm
: 60 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

::-

Address

:-

Phone number

:-

Occupation

:-

Education

:-

Relationship

: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)

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. 3.000.000,

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
Assalamualaikum bu Yurnalis
Waalaikum salam
Buk, ambo Randa, dokter muda Buliah...
disiko, buliah awak tanyo-tanyo
saketek buk?
Lah bara umua buk?
Tahun bara tu berarti buk?
Tanggal bara tu buk?
Jo sia ibuk kamari?

50
1964
1 Januari 1964
Sorang se nyo

Interpretation
Composmentis
Cooperative
Good time
orientation
Good personal
orientation

Ooo...ibuk dari ma tadi sabalum Dari rumah

Good place

kamari?
Dima rumah ibuk?

Jl. Dr. Sutomo, yang dibalakang SLB,

Baa kok ibuk kamari?

Lah acok barubek kamari buk?
Lah sajak bilo tu buk?
Dek a dulu awalnyo yang 5 tahun

Marapalam
Nio minta tambah ubek
Lah acok. Ibuk rutin kontrol kasiko
Kiro-kiro 5 tahun yang lalu
Suami ibuk nikah baliak.

yang lalu tu buk?

Tu jo ibuk baa?
Tu baa perasaan ibuk?
lai namuah makan sudah tu
Lalok ibu baa?

Jo ibuk masih lo. Ndak bacarai doh.

Sadiah, kecewa
Makan lai
Lalok susah, acok tasentak malam-

orientation

Depressive

malam
Lai ada pulang suami ibuk ka lai
rumah
Lai ado nyo ma agiah pitih Ndak ado doh
balanjo?
Tu baa untuk balanjo ibu sahari- Ibu karajo, dulu tu di bidan cici jadi
hari?
Tu kini ndak itu karajo doh lai?
Baa tu baranti karajo yang dulu?

cleaning service
Indak, kini karajo mambuek kue
Bos ibu berang- berang se, keceknyo
karajo ibu ndak barasiah doh, padahal
alah barasiah sadonyo ibuk buek. Tu

Tu baa prsaaan ibu rasonyo?

saketek lo gajinyo tu
Ndak smangat karajo, sadiah se hati,

Depressive
6

saking sadiah nyo kadang manangih

sorang se ibu, abis tu dibaok nyo dek
suami ibu barubek ka praktek dokter
Tu baa kecek dokter tu?

spesialis jiwa
Ibu dikasih ubek, tu disuruah kontrol

ka poli jiwa RSUP M. Djamil

Lai ibu lanjutakan kontrol ka poli Lai, teratur sampai kini
jiwa M Djamil?
Lai bakurang ndak keluhan ibu ?
Lai, lalok lah lamak
Tu satalah itu, ado masalah lo Ado, suami ibu manikah lo baliak
baliak ndak?
Bilo buk?
Tahun 2010, 4 tahun yang lalu
Tu baa perasaan ibu?
Iyo, sadiah hati
Kini baa perasaan ibu? Apo yang Kini ko agak sadiah hati rasonyo,
taraso kini bu?
Baa ko masih sadiah rasonyo kini?

Anak ibu ka kuliah, atau ka masuak

polisi, samantaro suami ibu ndak ado
mambantu biaya sakolah nyo,
Ibuk

ndak

mampu

rasonyo

mambiayaan anak ibuk sakolah 4

Baa tu buk?

tahun lai ko
Ibu karajo buek kuenyo, lah ndak ado

Depressive

se samangaik ibuk untuk mambuek

kue tu, tapi baa lah harus tetap ibu
mambuek kue ko. Ibu maraso ndak
sanggup kalau untuk mambiayaan
sakolah anak ibu.
(Sedih. Mengusap air mata)
Yang lain apo nan ibuk rasoan?
Iyo, itu se nyo
Kalau itu, ado ibuk mandanga Ndak ado doh
bisiak-bisiakan buk?padohal ndak

None
Halusination

ado urangnyo buk?

Ooo...kalau
mancaliak-caliak Ndak ado lo doh
7

hantu, malaikat gitu ado buk?

Mancium bau-bauan?bau harum Ndak ado doh
atau bau busuak, tapi ndak ado
sabananyo doh
Ado ibu cameh-cameh balabiahan? Ndak ado doh

No Anxiety

Berdebar-debar?
Sakik yang lain ado buk?, sakik Ndak ado doh
kapalo?paruik sakik?
Iyo lah buk, tarimo kasih banyak Iyo samo samo nak
yo buk
Explanation and Conclusion of Psychiatric Examination
Examination was done on September 1st, 11.30 a.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. General knowledge
e. Intelligence prediction

eutim

:
:
:
:
:
:
:

stable
good
echt
adequate
deep
wide
fast

:
:
:

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

:
:

good
hard to predict
average
8

f. Discriminative insight
g. Discriminative judgment
h. Intellectual decreasing

:
:
:

good enough
good enough
none

C. Sensation and perception abnormalities

1. Illusion
: none
2. Hallucination
:
Acoustic
: none
Visual
: none
Olfactory
: none
Tactile
: none
Gustatory
: none
D. Thought process condition
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
9

e.
f.
g.
h.
i.
j.

Sexual deviation
Echopraxia
Vagabondage
Pyromania
Mannerism
Others

:
:
:
:
:
:

none
none
none
none
none
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

10

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

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
11

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
Onset
Diagnosis
Family Support
Marital status
Economic
Medicine
Precipitating factor
Genetic
Others disease

Point
Adult
Mild Depressive episode
good enough
Married
Lower Middle class
Regularly
Clear
None
None

Clinical

dubia at bonam

Functional

dubia at bonam

Social

dubia at bonam

Good

Not good

12