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Recurrent Depressive Disorder

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Bed Site Teaching Report about Recurrent depressive Disorder
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   Bed Site Teaching Recurrent Depressive Disorder Current Episode Severe With Psychotic Symptoms OLEH Taufik Ramadhani P. 1443 Harris Putra Reza P. 1449 PRECEPTOR dr. Yaslinda Yaunin, Sp.KJ PSYCHIATRY DIVISION MEDICAL FACULTY OF ANDALAS UNIVERSITY RSUP DR. M.DJAMIL PADANG 2014  CASE REPORT A 27 years old male patient, came to the Mental Polyclinic of M.Djamil Hospital Padang on August 25, 2014 at 01:00 pm and escorted by father. The complaints were frequent crying, pensive, and speak for hisself since 3 weeks  before coming to the hospital. PATIENT’S IDENTITY  :  Name : Mr S Gender : Male Place, Date of Birth/Age : Salido, August 8, 1987 / 27 years old. Marital status : Not married Address : Kampung Laban Kelurahan Salido Sari Bulan Pesisir Selatan Occupation and School : Construction workers/   graduated from high school Religion : Islam Citizen : Indonesian Race : Minangkabau INTERNAL STATUS General appearance : Medium Blood pressure : 120/80 mmHg Pulse : Palpable strong, regular, frequency 82 x / min Breath : Abdominaltorakal, regular, frequency 18 x / min Temperature : 38,1 C Body shape : Asthenikus Height : 155 cm Weight : 50 kg Respiratory system : Inspection : Symmetrical on both left and right site in static and dynamic state   Palpation : Fremitus left side equal to the right side Percussion : Sonor throughout the lung fields Auscultation : Vesicular breath sounds, no ronkhi, and no wheezing Cardiovascular system : Inspection : Ictus is not visible Palpation : Ictus was palpable 1 finger on the medial side of LMCS RIC V Percussion : Cardiac border was obtained normal Auscultation : Pure heart sounds, regular rhythm, frequency 82x / min, no cardiac murmur Gastrointestinal system : Inspection : no bulge Palpation : Liver and spleen were not palpable Percussion : tympanic Auscultation : normal intestinal murmurs specific abnormalities : not found NEUROLOGICAL STATUS I.   Central nervous System (sensory) : sight, smell, hearing, taste, and touch were fine Symptoms of brain meningean stimulation : stiff neck negative Symptoms of increase intracranial pressure : projectile vomitting negative,  progressive headache negative   Eyes -   Movement : can be moved in any direction, nistagmus negative -   Perception : diplopia negative -   Pupil : round, isochors, -   Lights reflex : positive / positive -   Convergence reflex : was not performed  -   Cornea reflex : was not performed -   Ophthalmology : was not performed II.   Motoric -   Tone : Eutone -   Turgor : good -   Strength : 555 555 555 555 -   Coordination : Good -   Reflex : -   Physiologic (patella) : ++/++ -   Pathologic : Babinsky reflex negative III.   Sensibility : smooth and rough were good IV.   Vegetative neuron : eating, sleeping, and waking function were normal V.   Supreme functions : Activity of reading, writing, drawing, language and numeracy can be performed well VI.   Spesific disorder -   stiffness : none -   tremor : none -   nasal stiffness : none -   occulogiric crisis : none -   torticolis : none Laboratory Test 26 Agustus 2014 HB = 14,9 g/dl Ht = 44,4% Platelet = 242.000 /mm 3  Leukocytes = 9.280 / mm 3
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