Bed Side Teaching A 27 years old man was admitted to HB Saanin Hospital emergency unit on March 19th 2014

He was accompanied !y his "amily# with chie" complaint$ the patient was restless# irrita!le# angry# and hit his "ather 2 hours !e"ore admission He also con"essed that he heard %oice telling him to do it He slept & hours per days 'more sleep in the a"ternoon( and eat ) times per days with one portion o" each *atient was !eing li+e that "or the second time and had !een hospitali,ed in 2011 -he restlessness o" the patient is getting lesser a"ter care Patient identity: .ame / Age M0 2ender *lace and date o" !irth Marital status 0eligion 4ccupation / School 7iti,en -ri!e Address A. Internal Status 2eneral appearance Blood pressure *ulse 0espiration -emperature Body Shape Height ;eight $ 7omposmentis $ 110/:0 mmHg $ palpa!le# regular# :2 times per minute# $ toracoa!dominal# regular# 1: times per minute $ )&#:07 $ astenicus $ 170 cm $ 30 +g
1

$ $ $ $ $ $ $ $ $ $

Mr 0 / 27 years old 01 17 11 Male *adang# March 23th 2014 Single Muslim unemployed / not graduated "rom 5lectrical -echnic 6iploma in Andalas *olytechnic 'until )rd semester( 8ndonesian Minang+a!au 7omple1 *esona 8nanta 5 3# Alai *ara+ 9opi# *adang

7ardio%ascular system $ 8nspection *alpation *ercusion $ 8ctus cordis cant !e seen $ 8ctus cordis was palpa!le# 1 "inger medial away "rom <M7S 87S = $ 7ardiac edge $ >pper edge 87S 88# 0ight edge <S6# <e"t edge 1 "inger medial "rom <M7S 87S = Auscultation $ 0egular rhythm# :21 per minute# no heart murmur 0espiratory System $ 8nspection *alpation *ercusion $ Symmetrical in static and dynamic position $ ?remitus le"t @ right $ Sonor on le"t and right

Auscultation $ =esicular# no ron+hi 'A/A(# no whee,ing 'A/A( 2astrointestinal system $ 8nspection *alpation *ercussion $ .ot distended $ <i%er and spleen were not palpa!le $ -hympanic

Auscultation $ 8ntestinal sound 'B( normal Speci"ic disorder $ .o a!normality detected B. Neurological Status 7ranial .er%ous '"i%e senses( Meningeal Signs 5yes A A A A A A A Mo%ement *erception *upil <ight 0e"le1 7on%ergence 0eaction 7orneal re"le1 4phthalmoscopy e1amination $ ?ree to all direction $ .o nystagmus# no diplopia $ 0ound# isochoric $ B/B $ .ot e1amined $ .ot e1amined $ .ot e1amined $ =ision# smelling# hearing# tasting# and tactile are well $ .one

High 8ntracranial *ressure Signs $ .one

Motoric A A A A -onus 7oordination -urgor Strength $ 5utonus $ 2ood $ 2ood $ 2ood 333 333 A 0e"le1 333 333

$ *hysiologic $ *atella 0e"le1 'B/B( *athologic $ Ba!ins+i 0e"le1 'A/A( $ .o a!normality detected $ 2ood appetite# sleep well $ 0eading# writing# drawing# and calculating is well done $ .one $ 'B1( $ .one $ .one $ .one

Sensi!ility =egetati%e ?unction Basic ?unction Speci"ic disorder A A A A A A 0igid -remor -orticollis .asal sti""ness 4thers

4culogyric crisis $ .one

Allo Anamnesis .ame / Age 2ender Address *hone num!er 4ccupation 5ducation 0elationship $ Mrs < / 4: years old $ ?emale $ 7omple1 *esona 8nanta 5 3# Alai *ara+ 9opi# *adang $ 0:3211))2711 $ 5lementary school teacher $ Bachelors degree $ Mother

I.

Primary cause of hospitalization : -he patient was restless# irrita!le# angry# and hit his "ather 2 hours !e"ore admission He

also con"essed that he heard %oice telling him to do it He slept & hours per days 'more sleep in the a"ternoon( and eat ) times per days with one portion o" each *atient was !eing li+e that "or the second time and had !een hospitali,ed in 2011 -he restlessness o" the patient is getting lesser a"ter care *atients complaint today$ .one II. History of illness : 2 !"2 # $the month %as not remem&ered' -he patient didnt continue his study since 200: !ecause he couldnt handle his tas+s in college and had 2*A '2rade *oint A%erage( less than 2 He stopped in ) rd semester !ut he still too+ money "rom his parents "or the ne1t semester college payment He spent the money "or ser%icing his motorcycle and ga%e it to orphanages His parent was angry when they +new a!out the "act# especially his "ather who always pushes him hard to study well and !e success"ul person since he is a oldest child and the only one son in his "amily -hen# his parent ne%er care anymore a!out what he was doing# !ut his mother still ga%e him money 4ne day he went to his hometown# *aya+um!uh and got an accident According to medical e1amination there was no serious inCury# !ut a"ter the accident he loo+ed %ery shoc+# he didnt tal+ a word# couldnt sleep# and didnt want to eat He can mo%e his !ody spontaneously without a clear cause He went to neurologist and got medicines# !ut according to the "amily# a"ter some days there wasnt impro%ement o" his condition and he !ecame strange He started to !e irrita!le# easy to !e angry# and li+e to +iss his mother He also heard womans %oice telling him to do things -hen the "amily too+ him to psychiatrist and got medicines Because the "amily couldnt see impro%ement o" his condition# a"ter : months consuming drugs "rom psychiatrist# they went "or alternati%e treatment in their hometown that has !oarding system A"ter some wee+s# he was getting worse and the "amily decided too+ him home a"ter some wee+s# slowly# he got !etter and can wal+ normally

2 (( $the month %as not remem&ered' His "ather had a stro+e attac+# so he went to the hospital to see his "ather 8n hospital# he hit his !rother in law without reason so his "amily too+ him home But he continued to !e angry without reason and he wrec+ed household appliances So his "amily too+ him to HB Saanin Hospital and he got hospitali,ed "or a month He went home with a Duite condition He controls his condition regularly and too+ medicine o!ediently -he medicines are$ 0isperidone 211 ta! E 2 mg Haloperidol 211 ta! E 1#3 mg 7*F 111 ta! E100 mg 'his mother only ga%e 7*F when he started to tal+ed irrationally( -H* 211 ta! E 2 mg A"ter come home# he still doesnt ha%e any Co!# he Cust spent the time at home# or went to his hometown or his "riends home 2 () $*arch' He dran+ his "ather water and his "ather scolded him# !ut suddenly he !ecame angry and hit his "ather His "ather wanted to attac+ !ac+# !ut other "amilies tried to stop them His "ather "orced his mother to ta+e him !ac+ to the hospital -hen his "amily !rought him to the HB Saanin Hospital and he got hospitali,ed His mother con"essed that he dran+ a cup o" co""ee in the morning o" that day outside her super%ision Premor&id history 8n"ant 7hildhood -eenage $ !orn spontaneously# !irth was assisted !y midwi"e# no history o" Caundice# cyanosis# and sei,ure $ growth and de%elopment according to his age He li+es to play with "riends $ growth and de%elopment according to his age He li+es to play with "riends He was a %ery religious teenager and he li+ed to gi%e a speech in the mosDue Adolescence $ unemployed# still had a good relationship with his "riends at schools and college +ducational &ac,ground S6 SM* $ S6 . 0) Alai *adang# graduated in & years $ M-s. 1 *adang# graduated in ) years
3

SMA 7ollege

$ SM9. 2 *adang# graduated in ) years $ 5lectrical -echnic 6iploma in *olytechnic Andalas *adang# not graduated He didnt continue his study !ecause he couldnt handle the tas+s and 2*A G 2 He stopped in )rd semester

III.

-ccupation History >nemployed

I..

*arital History Single

..

Social +conomic history She li%ed with his "ather# mother# and ) sisters in a permanent house -here is electricity

and the water source is "rom *6AM Monthly income o" the "amily is more than enough "or the patient 8ncome ?athers salary Mothers salary Sisters allocation 4utcome ?amily cost ;ater cost 5lectricity cost 0p 4 000 000#A 0p 0p 70 000#A :0 000#AB 0p 2 300 000#A 0p 2 300 000# 0p 1 000 000#AB 0p & 000 000#A

0p 4 130 000#A 0emaining cost 0p 1 :30 000#A

.I.

/amily history of illness

-here were no "amily mem!ers that has same symptoms li+e this or has mental disorder

&

0raphic of illness
Stopped his study His parents were angry His "ather got a stro+e attac+ His "ather irritate his "eeling

2008-2009

2011

(3) 2014

Autoanamnesis1 *arch 2(th 2 (): 2uestions Ans%ers Assalamualai+um !ang 0o!!i ;aalai+um salam Bang# am!o <ani do+ter muda Buliah disio+o# !uliah awa+ caritoAcarito Co a!ang +ini !angJ <ah !ara umua a!ang !angJ -ahun !ara tu !erarti !angJ -anggal !ara tu !angJ 4oK <ah !ara hari disi+o !angJ Sia yang !ao+ +amari !angJ Sia se tu !angJ <ansuang di !ao+ +amari a!angJ 27 19:7 23 Maret 19:7 <ah 4 hari 9eluarga MamaK papaK omK adia+Aadia+ .da+K +a 826 di mu+o dulu Hari Interpretation 7omposmentis 7ooperati%e

2ood time orientation 2ood personal orientation 2ood place orientation Hemmung

+o !aru +a ?lam!oyan +o Baa caritonyo !ang# +o+ di!ao+ 'senyum le!ar# +onta+ mata ada# tapi a!ang +amari samo +eluargaJ tida+ menCawa!( BangKJ Baa !angJ Baa +o+ Baca+a+ samo papa di!ao+ +amariJ Baca+a+J Baa caritonyo tu !angK 'lama menCawa!(

Manga a!ang wa+tu tuJ .da+ nio ma+an Lam !ara memangnyo +eCadiannyo Maghri! !angJ Alun ma+an siang a!ang lai doJ -u !aa lai !angJ BangKJ 'tertawa( alun 'tersenyum senang( 8yo tu !erang papa#!angih

se <ac+ o" attention 7on"a!ulation

calia+nyo -u +anai !erang a!angJ Mama nel"on om Manga nel"on om !angJ Bao+ a!ang +a rumah sa+i+ 8tu se nyo !angJ A!ang nda+ ado .da+ !erang +a papaJ 8yo !ana tu !angJ -u manga a!ang 8yo 6e+ !aca+a+ de+ itu se di !ao+ +a rumah sa+i+J Baca+a+ !aa +o !angJ A!ang !erang loJ Baca+a+ mului+J Baca+a+ mului+ se nyo !angJ Mang lainKJ Ado a!ang +aya+ malo+o+ papa *apa !erang .da+ 8yo 8yo 'tertawa( .da+K

6istur!ed discriminati%e insight

a!ang gai na+J *apa a!ang ado malo+o+ a!angJ 8yoK -u diam se a!angJ 8yoK Ladi !aa +o+ a!ang yang di !ao+ 6isunti+ +a rumah sa+i+J Supayo disunti+J 8yoK *apa a!ang nda+ disunti+J A!ang 'tertawa( yang disunti+J A!ang tu yang salahJ Baa +o+ a!ang yng disunti+J Baa !angKJ 'tertawa( A!ang sa+i+ A!ang alah duo +ali disi+o ma 6i ?lam!oyan +o 8yo !angJ Bilo yang pertamoJ -ahun 2011 Manga wa+tu tu tu !ang# +o+ 'tertawa( dirawat a!angJ .da+ ta+anaK 9an !aru tu !angK +anaA+ana lah 'tertawa( dulu !angK Baa caritonyo wa+tu tu tu !angJ 9ini apo yang taraso !angJ 'tida+ menCawa!( 'tersenyum le!ar( 6istur!ed discriminati%e Cudgement

<ac+ o" memory

8nappropriate
:

<ai sanang disi+o !angJ Sanang 8nda+ 'tapi tersenyum senang( hati a!ang !antua+nyo ha <ai !anya+ +awan disi+oJ ;a+tu sa+i+ tu !aa rasonyo !angJ Berang !ana a!ang rasonyoJ 8nda+ 'masih tersenyum senang( 'tertawa( .da+ tauK 'tertawa(

a""ect

.da+ tauK 9alau sadang sa+i+ +o lai a!ang Ado tadanga suaroAsuaro !angJ Suaro apo tu !angJ .yo mangece+ +a a!ang Suaro apo Auditoric halutination

tuJ Baa suaronyo !angJ Suaro a!angJ .da+K suaro padusi Mangece+nyo +a a!ang 8yo <ai sa!ana tu !angJ 9a a!ang se Mo !ana nyo mangece+ nyo !angJ .da+ tauK Apo yang nyo +ice+ an emangnyo 9araCoanlahK +araCoanlahK !angJ -u a!ang +araCoanJ .ampa+ urang nyo !angJ Atau ado .ampa+ !ayangA!ayangJ Mencium !auA!au aneh !angJ Atau ado nyo +acaA+aca a!angJ Apo tu !angJ .da+ !angK apo +atonyo !angJ Ninda+O +atonyo !ang/ .da+ !ang .da+ ado apoAapo do 8nda+ lahK .da+ .da+ adoK .da+ Haa tu nyo ha Ado tadangaJ Ninda+O 8yo .da+ tadangaJ 8yo .da+ tadanga do yoJ

6elusion o" in"luence

Auditoric halutination

Sa!ana tu !angJ .da+ ado tadanga do !ang 'tersenyum senang( Ado yang taraso !aulang Cadinyo 8yo BaulangAulang rasonyo di +apalo di +apalo a!ang yang di+ece+an tu +o !angJ Bagema rasonyoJ 8yoK 9alau pi+iran a!ang di!aco urang .da+K lain rasonyo ado !angJ Atau a!ang !isa mam!aco pi+iran .da+ urangJ Ladi +ini apo yang taraso !angJ 'mengang+at !ahu( .da+ tau 8nappropriate a""ect
9

-hought eco

.da+ nio pulang doJ Baa tuJ 9ama CalanACalan !angJ

'senyumAsenyum( .io so!o+ papa LalanACalan 9a pantai 8ncoherent

9a +ampuang a!ang 9ampuang a!ang di pariamanJ 6i paya+um!uah 9alau +alua dari si+o apo rencana 'tertawa( !angJ <ah +araCo a!angJ 6ima !angJ Apo tu !ang +araConyoJ Alah 6i *<. <istri+

Masang

instalasi

lisri+

rumahArumah +o haK 4oK lah lamo a!ang +araCo Alah <ah ) tahun disituJ -api a!ang sa+i+ tahun 2011 # 8yo -ahunan masih +araCo disituJ -amat apo a!ang dulu !angJ SM-8 Se+olah Menengah -e+ni+ 8yo 8ndustriJ -amat ) tahun !angJ Sudah tu langsuang +araCoJ 4oK dima +uliah !angJ *olite+ni+ >nandJ Lurusan apo !angJ Ha Ma ado Curusan sastra !angJ -api a!ang dari SM-8 Am!ia+ 8yo .da+K +uliah dulu 6i poli 8yo Sastra Ado 8yo

6elusion o" grandeur

sastra a!angJ Sastra apo !angJ Sastrawan Ma ado Curusan sastrawan !ang Ado Mang ado tu sastra 8ndonesia# 8ndonesia sastra 8nggris Bara tahun tu !angJ 8yo# !ara tahun tu !angJ Sudah tu +araCo a!ang di *<.J Bisa yo !angJ A!ang tapi Sastrawan 8ndonesia 64 4 tahun 8yo Bisa Awa+ sewo

sastrawanJ Sewo +o !aa !angJ -ahunan di sewo *ulang dari si+o a!ang nio +araCo 8yo !alia+ disinanJ A!ang !ilo rencana pulang .da+ tauK 8nappropriate
10

emangnyoJ Sa+i+ apo a!ang +ini +oJ Ma+an u!e+ a!angJ >ntua+ apo tu !ang ma+an u!e+J Ladi a!ang nda+ nio pulangJ Baa +o+ a!ang dirawatJ Bara lamo a!ang +a dirawatJ Sa!ulanJ .da+ nio pulang a!angJ Ladi apo sa+i+ a!ang +ini +oJ 9ini nda+ ado yang tarasoJ SedihJ SanangJ Mo lahK mo+asi yo !ang

'tersenyum( .da+ tauK 8yo Ma+an u!e+ taruih 'tertawa( 6i rawat dulu Supayo sehat Sa!ulan .da+ !aa !ia sehat dulu 'senyumAsenyum( .da+ ado 'tersenyum le!ar(

a""ect

8stirahatlah a!ang lai Assalamualai+um

;aalai+um salam

+3planation and 4onclusion of Psychiatric +3amination 51amination was done on March 21st# & 00 p m 1 2eneral appearance 7onsciousness/sensorial Attitude Motoric ?acial e1pression =er!ali,ation *sychical contact Attention 8nitiati%e $ $ $ $ $ $ $ $ composmentis/good cooperati%e acti%e rich spea+ clearly could !e done / proper enough / long enough good enough good enough

*atientss writing and drawing is present 2 Speci"ic condition A A""ecti%e 1 2 A""ecti%e condition 5motional $ a ! Sta!ility 7ontrol $ $ sta!le good
11

inappropriate

c d e " g

5cht/unecht 5in"uhlung 6eep/shallow 6i""erentiation scale 5motional "low

$ $ $ $ $

echt inadeDuate shallow narrow "ast

B 8ntellectual condition o" "unction a ! c d e " g h Memory 7oncentration 4rientation 2eneral +nowledge 8ntelligence prediction 6iscriminati%e insight 6iscriminati%e Cudgment 8ntellectual decreasing $ $ $ $ $ $ $ $ less di""icult time# personal# and place orientations are good hard to predict a%erage distur!ed distur!ed none

7 Sensation and perception a!normalities 1 8llusion 2 Hallucination Acoustic =isual 4l"actory -actile 2ustatory 6 -hought process condition 1 2 Speed o" thought processs Puality o" thought process$ a 7learness and sharpness $ not clear enough and not sharp enough
12

$ none $ $ present# the sound o" a woman telling him to do things $ none $ none $ none $ none

slow

! 7ircumstantial c 8ncoherent d Sperrung e Hemmung " ?light o" ideas g =er!igeration h *reser%ation ) -hought condition a 7entral pattern ! *ho!ia c 4!session d Suspicion e 6elusion " 7on"a!ulation g 6ominance# animosity h 8n"erior "eeling i Much / little C 2uilty "eeling + Hypochondria l 4thers

$ $ $ $ $ $ $

none none none present none none none

$ $ $ $ $ $ $ $ $ $ $ $

none none none none delusion o" in"luence# delusion o" grandeur present none none little none none none

5 8nstinctual impulse and !eha%ior a!normalities a A!ulia ! Stupor c 0aptus/impulsi%ity d 51citement state e Se1ual de%iation " 5chopra1ia $ $ $ $ $ $ present none presented in ) days ago# su!sided since a day ago none none none
1)

g =aga!ondage h *yromania i Mannerism C 4thers ? 4%er an1iety 2 0eality testing a!ility *56TIP6+ A7IS 8+S5*+ A1is 8 7linical Syndrome

$ $ $ $ $ $

none none none none none !eha%ior# thought# "eeling are distur!ed

-he patient was restless# irrita!le# angry# and hit his "ather 2 hours !e"ore admission He also con"essed that he heard %oice telling him to do it He slept & hours per days 'more sleep in the a"ternoon( and eat ) times per days with one portion o" each *atient was !eing li+e that "or the second time and had !een hospitali,ed in 2011 -he restlessness o" the patient is getting lesser a"ter care 2eneral Appeareance$ composmentis cooperati%e# good sensorium# initiati%e 'A(# cooperati%e# acti%e motoric# rich "acial e1pression# lac+ o" initiati%e# lac+ o" attention# tal+ clearly# physical contact can !e done# proper enough and long enough Speci"ic condition$ a ! A""ecti%e condition$ inappropriate# sta!le# control is good# echt# inadeDuat# shallow# narrow# "ast 8ntellectual condition and "unction$ memory is less# concentration is di""icult# discriminati%e insight distur!ed# discriminati%e Cudgment is distur!ed# orientation is good# intelligence prediction is a%erage c d e " Sensation and perception a!normalities$ accoustic halutination -hought process condition$ slow# not clear and not sharp enough# incoherent# hemmung# delusion o" in"luence# delusion o" grandeur# con"a!ulation 8nstinctual dri%e and !eha%ior a!normalities$ a!ulia# raptus/impulsi%ity presented in ) days ago# su!sided since a day ago 4%ert an1iety$ none
14

0eality testing a!ility$ !eha%ior# "eeling and thin+ing are distur!ed

A1is 88 $ *ersonality 6isorder and Mental 0etardation 6isorders *ersonality$ outgoing# has "riends Mental retardation$ none A1is 888 $ 2eneral Medical 7ondition Head traumas history was a!sent .o history o" malaria# typhoid# or !rain and neurological disease

A1is 8= $ *hsychosocial Stressor and 5n%ironment His "ather always pushes him hard to study well and !e a success"ul person and his "ather also easy to !e angry to him He couldnt continue his study !ecause he couldnt handle tas+s and his 2*A G 2 Being Co!less since he stopped to study

A1is =$ 2lo!al Assessment o" ?unction 6aily acti%ity couldnt !e done since ) days ago Social relationship couldnt !e done since ) days ago Spending time with watching -=# recreation# couldnt !e done since ) days ago

*56TIP6+ A7IS 9IA0N-SIS 8 88 888 8= = ? 23 0 Schi,oa""ecti%e disorder# manic type .o diagnosis .o diagnosis Being pushed hard and rudely !y his "ather# he couldnt continue his study and !eing Co!less 2A? 31A&0

9I//+8+NTIA6 9IA0N-SIS
13

8 88 888

? 20 1 Schi,ophrenia he!ephrenic ? )1 2 Bipolar a""ecti%e disorder# current episode manic with psychotic symptoms ? 20 ) >ndi""erentiated schi,ophrenia

TH+8AP: 0isperidon 2 1 2 mg 6ia,epam 1 1 2 mg

S500+STI-N /-8 TH+8AP: 7*F 2 1 100 mg ?or long term therapy$ 8nCection o" Haldol decanoas 30 mg 8M# once a month *sychotherapy to the patient and "amily

P8-0N-SIS -nset 9iagnosis /amily Support *arital status +conomic *edicine /a,tor pencetus 0enetic -thers disease 7linical ?unctional Social $ $ $ Point Adult Schi,oa""ecti%e disorder# manic type .ot good enough Single Middle Q higher class 0egularly 7lear .one .one du!ia at malam du!ia at malam du!ia at !onam 0ood ; Not good ; ; ; ; ; ; ; ;

1&