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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 GMOPolyclinic Prof. RSJ. HB Saanin Padang on 8 November2013 at 9:30 am, the complaints would like to adddrugs prescription.Pasien treatment for the secondtime with complaints can not sleep, crying, eating less,often suspicious of others, feel inferior, and the silencein the room . Ever seen a black shadow which

whispered something into his ear. Patientsexperiencing this since 1.5 months ago when herhusband 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 highschool

•

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 (-/-), nowheezing (-/-)



• Gastrointestinal system :

• Inspection : Not distended

•

Palpation : Liver and spleen were notpalpable

• 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



• Autoanamnesa



• Primary cause of hospitalization :

• none.

• Patient’s complaint now : Patient would like to

add drugs prescription. She treatment for thesecond time with complaints can not sleep,crying, eating less, often suspicious of others, feelinferior, and the silence in the room . Ever seen ablack shadow which whispered something into

his ear. Patient experiencing this since 1.5 monthsago when her husband were caught cheatingwith 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 ablack shadow whispered something into his ear. Previouspatient husband caught having an affair with anotherwoman. The patient had never been treated for mentalillness before this incident.

•

• Premorbid history

• Infant : born spontaneously, birth was assisted bymidwife, no history of jaundice, cyanosis, and seizure.

• Childhood : growth and development according to his age.

• Teenage : growth and developmentaccording 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 electricitythere. The water source is from the well. Monthly income is enough forthe 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.



• 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 : fast

• Quality of thought process:

• Clear and sharp : clear enough and sharp enough

• Circumstantial : none

• Incoherent : none

• Sperrung : none

• Hemmung : none

• Flight of ideas : none

•

Verbigeration : none• Preservation : none

•



• Thought condition

• Central pattern : none

• Phobia : none

• Obsession : none

• Delusion : none

• Suspicion : yes, since 1.5 months ago, was reduced from 4weeks ago

• Confabulation : none

• Repulsion : none

• Inferior feeling : yes, since 1.5 months ago, was reducedfrom 4 weeks ago

• Much/little : much

• Feeling guilty : none

• Hypochondria : none

• Others : none



• 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. Shetreatment for the second time with complaints can not

sleep, crying, eating less, often suspicious of others, feelinferior, and the silence in the room . Ever seen a blackshadow which whispered something into his ear. Patientexperiencing this since 1.5 months ago when her husbandwere caught cheating with another woman.

•

General Appeareance: composmentis cooperative, goodsensorium, good attention, initiative (+), cooperative, activemotoric, rich facial expression, clear talk, physical contactappropriate and long.



• Specific condition:

• Affective condition: normotim, stable, control is goodenough, echt, adequat, deep, narrow, fast

•

Intellectual condition and function: Memory is goodenough, Concentration is good enough, Discriminativeinsight 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 trauma’s 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 anotherwoman

• Axis V: Global Assessment of Function

• - Social relations (visiting friends, attending community events) hasbeen able to do since 4 weeks ago.- Daily work (cooking, washing, cleaning the house) is notcompromised.

- Charge time (watching TV, sports, reading) has been able to dosince 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 anotherwoman

• GAF 51-60



• DIFFERENTIAL DIAGNOSIS

• F 41.1 Comprehensive Anxiety DisordersF 43.2 Adjustment DisordersTHERAPY

• - 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

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