CLINICAL INTEGRATIVE MODULE - SCENARIO 1

INDEPENDENT REPORT

SCENARIO 1
dr. Meidyta Sinantryana Widyaswari, Sp.DV

MAULIDATUL JINANI FIRDAUSYAH - 6130020049

 VALIDITY SHEET
Tutor : dr. Meidyta Sinantryana Widyaswari, Sp.DV
 SCENARIO 1
A man, 27 years old, came to the doctor with
complaints of difficulty falling asleep. The patient
asks the doctor to keep his illness a secret

MIK - SEMESTER 6
TPL - PPL
POMR
MIND MAPPING
 LEARNING OBJECTIVE
1. Students can understand the Definition and Classification of Insomnia
2. Students can understand the Differential Diagnosis of the Above Case
(Difficulty Sleeping)
3. Students can understand Etiology and Pathogenesis
4. Students can understand the Physiology of Sleep
5. Students can understand the Pathophysiology of symptoms
6. Students can understand the Risk factors, Complications and Prognosis of
Insomnia
7. Students can understand the Flow of Insomnia Diagnosis
8. Students can understand the Management and Prevention of Insomnia
9. Students can understand the Code of Ethics for Patient Confidentiality
10. Students can understand Islamic Aspects in the Case Above
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DEFINITION AND CLASSIFICATION OF INSOMNIA
Definition
Insomnia is difficulty falling asleep, maintaining sleep, or sleep that is not restful for 1 month or more

Classification
a. According to Levenson, Kay & Buysse, (2014) that there are two types of insomnia (based on time) :
Acute Insomnia
Chronic Insomnia
b. According to Perlis & Gehram (2013) the classification is based on the form of insomnia, namely:
Difficulty in Initiating Sleep (DIS)
Difficulty in Maintaining Sleep (DMS)
Early Morning Waking (Sleep Offset Insomnia)
c. Based on the cause
Primary Insomnia
Secondary Insomnia
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DIFFERENTIAL DIAGNOSIS OF THE ABOVE CASE (DIFFICULTY SLEEPING)
a. Disomnia
Insomnia
Hipersomnia
Narkolepsi
Disruption of the circadian cycle

b. Parasomnia
Somnabolisme
Night terorris
Nightmare
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ETIOLOGY AND PATHOGENESIS
Etiology
Stress and work pressure
Disruption of circadian rhythms
Behavioral disorders
Environmental factor
Unhealthy diet

Pathogenesis
In the body serotonin is converted into melatonin which is produced by the pineal gland in the brain which functions to help you feel
relaxed
when it's dark melatonin levels will start to increase and send a message to the body to fall asleep
Lesions in the sleep control center in the hypothalamus can also result in a sleep alert state
Lesions of the pharynx or anterior hypothalamus cause (transient) insomnia
In people who are in a state of stress or anxiety, the levels of this hormone will increase in the blood which will stimulate the sympathetic
nervous system so that a person will continue to be awake or awake.
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PHYSIOLOGY OF SLEEP
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PATHOPHYSIOLOGY OF SYMPTOMS
Sleep is a biological rhythm that works 24 hours which aims to restore stamina to return to
activities. Sleep and awakening are regulated by the brain stem, thalamus, hypothalamus and
several neurohormones and neurotransmitters are also associated with sleep. The product
produced by cerebral mechanisms in the brainstem is serotonin. Serotonin is a neurotransmitter
that plays a very important role in inducing drowsiness, as well as the working medulla of the
brain.

In the body serotonin is converted into melatonin which is a catecholamine hormone that is
produced naturally by the body. Lesions in the sleep control center in the hypothalamus can also
result in a sleep alert state. The released catecholamines produce the hormone norepinephrine
which stimulates the brain to increase activity. Stress is also a trigger factor, where in a state of
stress or anxiety, catecholamine hormone levels will increase in the blood which will stimulate the
sympathetic nervous system so that a person will stay awake.
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RISK FACTORS, COMPLICATIONS AND PROGNOSIS OF INSOMNIA
Factor risk
olderly
female gender
co-morbidities (depression and other illnesses)
Low socioeconomic status causes insomnia
Complications
Complications resulting from insomnia can affect brain function. The brain uses sleep as an active process where
when a person sleeps the brain will train all nerve cells by passing signals of electrical activity through all nerve
cells. When the brain's nerve cells do not get enough sleep, the work of brain functions in terms of storing or
retrieving information and the ability to tolerate stressful situations and function at a higher level can be
disrupted and not optimal.

Prognosis
The long-term prognosis of primary insomnia is very good if intervention and treatment are carried out properly
good and on time (Fernandez, 2013)
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STUDENTS ARE ABLE TO EXPLAIN HOW TO DIAGNOSE INSOMNIA
Anamnesis
Ask if the complaint about the sleeplessness is related to problems initiating sleep,
maintaining sleep, waking up too early, sleep that is not refreshing or preparation.
Also ask about onset, frequency, comorbidities, aggravating and mitigating aspects to help
establish the diagnosis.
Also ask for a sleep schedule including bedtime, sleep latency, length of sleep, time to trigger
back to sleep, wake time, bed freeze time, total sleep time.
Also ask about daily activities such as work schedules, meals, exercise, length and time of
naps
Also ask about medical conditions (cardiovascular, pulmonary, nervous, gastrointestinal, renal,
endocrine), psychiatric (depression, bipolar disorder, anxiety, panic psychosis) and substance
use such as nicotine, alcohol, caffeine)
Supporting investigation
Sleep-wake diary
Actigraphy
Polysomnography
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MANAGEMENT AND PREVENTION OF INSOMNIA
Management
Insomnia is a symptom, not a diagnosis, so it is a cytomatic therapy. While insomnia isa
symptom, it can become very disruptive of the activity and productivity of sufferers, especially
those with a productive age. Therefore, the sufferer deserves proper therapy. The approach to
therapy with insomniacs can be pharmacological or non-pharmacological, based on weight and
travel beyond the symptoms of insomnia itself.
A. pharmacology:
1. Benzodiazepine
2. Non-benzodiazepine:Zolpidem, zaleplon
3. Miscellaneous sleep abusive agent
Medicines from this class are said to be able to shorten the onset of sleep and reduce the
frequency of awakening during sleep cycles. But this information still has no significant evidence.
One example is melatonin, antihistamine and antidepressant
B. non-pharmacology
1. Stimulus control
2. Sleep ristiction
3. Slepp of hygiene
4. Cognitive therapy (Ghaddafi, m,2022).

Prevention:
Insomnia can be prevented by further avoiding the causes of insomnia according to the putu
arysta and I gusti beautiful ayu, 2013) of the many factors that cause insomnia: stress, depression,
chronic disorders, accompanying medications, poor diet, caffeine, nicotine, and alcohol, caffeine
and alcohol are stimulants and alcohol can disrupt sleep patterns, and lack of exercise can also
be a significant sleep factor. (Afriyani, R.et all,2022)
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CODE OF ETHICS FOR PATIENT CONFIDENTIALITY
In the case above, the patient asks to maintain the confidentiality of the patient's illness from the doctor.
ethical principles This includes the principle of autonomy. The principle of autonomy is a moral principle
that respects patient rights, especially the patient's right to autonomy (the rights to self-determination.
Someone whose autonomy is limited is someone who is controlled by another person or someone who are
unable to act according to their desires and plans (Suryadi, 2009).
These methods include:
1. Conveying the truth or real news (tell the truth)
2. Respect the privacy of others (respect the privacy of others)
3. Protect confidential information (protect confidential information)
4. Obtain consent for interventions with patients
5. Help others make important decisions (when ask, help others make important decisions)
Apart from that, the principle of patient autonomy must also be protected because it is stated in the
Indonesian medical code of ethics guidebook in article 16. which states, every doctor is obliged to keep
secret everything he knows about a patient, even after the patient died (IDI, 2012).
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ISLAMIC ASPECTS IN THE CASE ABOVE
Rasulullah SAW taught his people every time they are going to sleep to do good activities to get a
good night's sleep. Activities that are sunnah Rasulullah SAW before going to bed. Activities before
going to bed consist of:
1. Washing hands with soap, brushing teeth, performing ablution once each
2. Cleaning the bed while reciting Basmallah 3 times.
3. Reading Basmallah followed by listening to murottal Al-Qur'an surahs Al-Ihlas, Al-Falaq, An-Nas
and verses of each chair 3 rounds for 8 minutes 50 seconds. After finishing listening to Murottal
Al-Qur'an blow into the hand then diusapakan to the whole body as much as 3 times then read
Alhamdulillah.
4. Do dhikr consisting of Subhanallah, Alhamdulillah, Allahu Akbar each 33 times with use prayer
beads.
5. Set the sleeping position on the right side, read the prayer before going to bed, say
Astaghfirullaahal'azihiimi until you fall asleep (Princess el at , 2018).
 CONCLUSSION
Rasulullah SAW taught his people every time they are going to sleep to do good activities to get a
good night's sleep. Activities that are sunnah Rasulullah SAW before going to bed. Activities before
going to bed consist of:
1. Washing hands with soap, brushing teeth, performing ablution once each
2. Cleaning the bed while reciting Basmallah 3 times.
3. Reading Basmallah followed by listening to murottal Al-Qur'an surahs Al-Ihlas, Al-Falaq, An-Nas
and verses of each chair 3 rounds for 8 minutes 50 seconds. After finishing listening to Murottal
Al-Qur'an blow into the hand then diusapakan to the whole body as much as 3 times then read
Alhamdulillah.
4. Do dhikr consisting of Subhanallah, Alhamdulillah, Allahu Akbar each 33 times with use prayer
beads.
5. Set the sleeping position on the right side, read the prayer before going to bed, say
Astaghfirullaahal'azihiimi until you fall asleep (Princess el at , 2018).
 REFERENCE
Rasulullah SAW taught his people every time they are going to sleep to do good activities to get a
good night's sleep. Activities that are sunnah Rasulullah SAW before going to bed. Activities before
going to bed consist of:
1. Washing hands with soap, brushing teeth, performing ablution once each
2. Cleaning the bed while reciting Basmallah 3 times.
3. Reading Basmallah followed by listening to murottal Al-Qur'an surahs Al-Ihlas, Al-Falaq, An-Nas
and verses of each chair 3 rounds for 8 minutes 50 seconds. After finishing listening to Murottal
Al-Qur'an blow into the hand then diusapakan to the whole body as much as 3 times then read
Alhamdulillah.
4. Do dhikr consisting of Subhanallah, Alhamdulillah, Allahu Akbar each 33 times with use prayer
beads.
5. Set the sleeping position on the right side, read the prayer before going to bed, say
Astaghfirullaahal'azihiimi until you fall asleep (Princess el at , 2018).
THANK YOU