Case Report Session

RECURRENT MILD DEPRESIF DISORDER

WITH SOMATIC SYMPTOM

BY :
SRI GANESH

BP/P : 0910314132 / P.1521

VASHTI RESTI PUTRI FIRDAUS

BP/P : 1010313040 / P.1529

PRECEPTOR:
Dr. YASLINDA YAUNIN SP. KJ

PSYCHIATRY DIVISION
MEDICAL FACULTY OF ANDALAS UNIVERSITY
RSUP DR M DJAMIL PADANG
2015
0

PSYCHIATRIC PATIENTS STATUS

A female patient 62 years old come to Poli Jiwa RSUP DR. M. DJAMIL Padang by
herself on January 27th 2015 with the symptom is reguler control.
Patients identity:
Name

: Mrs. SA

Gender

: Female

Age

: 62 years old.

Marital status

: Married

Address

: Sati, Pariaman, West Sumatera

Occupation and School : Not Working

Religion

: Moeslem

Citizen

: Indonesian

Race

: Minangkabau

Internal Status
General appearance

Compos Mentis

Blood pressure

130/70 mmHg

Pulse rate

84 x per minute

Temperature

36,6 oC

Cardiovascular system

No disorder found

Digestive system

No disorder found

Specific disorder

No disorder found

Neurological Status
GCS 15, pupil reflex positive, corneal reflex positive
Cranial nerves

: Vision, smelling, taste, hearing, tasting and tactile are all

normal

Meningeal Signs

: No signs present

Increased Intercranial Pressure : Projectile vomiting (-),Progressive headache (-)

1

Eyes
-

Movement

: Free to move in all directions

Perception

Pupil

: Round and isochoric

Light Reflex

: +/+

Convergence

Not examined

Opthalmoscopy

Not examined

Motoric

No nystagmus, no diplopia

: Eutonus, Eutrophic, no tremor

Muscle strength superior extremity 555/555,
inferior extremity 555/555

Sensibility

No disorder found

Specific disorder

No disorder found

Autoanamnesis (27th of January 2015)

QUESTION

ANSWER

INTERPRETATION

Selamat pagi bu, perkenalkan kami Iya, boleh

Compos

dokter muda Vashti dan dokter

Cooperatif

muda Ganesh, boleh kami tanyatanya tentang keluhan sakit ibu?

Nama ibu siapa?

Ibu Siti Ainsah

Darimana buk?

Pariaman

Bara umua ibuk kini?

62 tahun

Jadi apo keluhan ibuk kamari?

Ibuk ndak bisa lalok 3 hari ko

Apo penyebabnyo tu buk? Ado Ndak ado do, ndak do ibuk Afek eutim
pikiran apo ibuk?

pikian apo-apo, dulu ibuk pernah

lo ndak bisa lalok salamo 5
bulan, yo subana ndak laloklalok ibuk 5 bulan tu

Baa bisa ndak bisa lalok ibuk 5 Antahlah, ibuk ndak lo tau do
bulan dulu tu?
Baa caritonyo yang ndak bisa lalok Ibuk dulu ndak bisa lalok 5
5 bulan tu buk?

bulan, awalnyo ibuk pai se ka

dokter umum, nyo agiah ubek
hipertensi se, lah babarapo kali
ibu baliak ka dokter umum ndak
jo bisa-bisa lalok, tu akhirnyo
nyo suruah ibuk cubo barubek
ka M. Djamil ko

Jadi bilo ibuk barubek kamari Bulan Agustus patang

partamo kali?
Lai kontrol teratur ibuk kamari?

Ibuk iyo ndak terakhir kontrol

lah lamo, 3 bulan lalu lah kirokiro

Baa ibuk ndak kontrol waktu tu?

Ibuk maraso ndak sakik lai do,

3

Mentis

manga ibuk kamari lai

Ibuk ado ndak mandanga-danga Pas sakik dulu iyo, ibuk kan
bisikan atau suaro-suaro?

dulu

sering

tajago

tangah Halusinasi akustik dulu

malam, tu ibuk kayak mandanga ada, kini tidak

ado urang mamanggia namo
ibuk Sah, tapi kini ndak ado
lai do
Kalo bisikan kayak yang jaek-jaek Ndak ado do, cuman namo ibuk
gitu ado ndak buk?
Kalau

mancaliak

se
bayangan- Ndak ado

bayangan ado buk?

Ado keluhan lain ndak ibuk?

Badan ko rasonyo sakik-sakik, Keluhan somatoform

tu angek-angek, kaki ko lamah
se rasonyo, tulang sakik-sakik,
leher ko tagang se rasonyo

Alah pariso labor ibuk?

Alah, waktu tu lah dipariso

sadolahnyo,

lai

normal

se

sadolahnyo keceknyo
Ado ndak ibuk maraso sadiah- Kadang
sadiah sampai nio nangih?

ado,

mancaliak

misalnyo

anak mudo,

kalo Depresi
ibuk

takana jo anak ibuk, tu sadiah se

ibuk, anak ibuk alah kawin
sadolahnyo
Kini baa perasaan ibuk?

Kini biaso se

Ibuk tau kini tanggal bara?

Tanggal 27 Januari 2015

Orientasi

Presiden awan kini ibuk tau sia?

Jokowi mah

terganggu

Iyolah buk, sagitu se dulu, makasih Iyo nak

yo buk atas waktunyo

MEDICAL RECORD (AUTOANAMNESIS)

1. Main reason of Hospitalization
4

tidak

Cant sleep since 3 days ago.

2. History of Illness
Year 2009
Patient has been sick before about 6 years ago, then went to Public Health Center and got
CPZ, haloperidol, and THP. Her husband died about 1 year before, in 2008. Since that,
she has been feeling sad.
Year 2014
In the month of June 2014, she cant sleep again, her body felt pain, and appetite
decrease, then she went to General Practisioner, and got hypertention medication, she
controlled with the GP several times, but the symptom still exist, and finally advised by
the GP to go to Dr. M. Djamil General Hospital Padang. She came to the Psychiatry
Policlinic in August 2014, and got Risperidon 2x1 mg, Diazepam 1 x 2 mg, Tilsan 1 x 25
mg, dan B1 2 x 100 mg. After consuming the medications she felt better and could sleep
again, and her appetite began to increase. She was asked to control regularly to the
psychiatry policlinic, but since November 2014 she did not control because she felt she
had no complaint. .
Year 2015
Patient complained cannot sleep since three days ago, she slept at 21.30 and suddenly
woke up at 01.00, and after that could not sleep again. She also felt pain in her body,
heaty, weak in her leg, bone pain and stiffness at her neck. Sometimes she felt sad and
want to cry if she thinks about her children and her late husband.
3. Premorbid History
Infant

: born spontaneously, birth was assisted by midwife, no history of

jaundice, cyanosis, or seizure.

Childhood

: growth and development suitable for his age.

Adolescence : patient have some friends and like doing social things
Adult

: patient have some friends, but prefer to stay at home rather than being

outside
5

Educational Background
Educated till third year of senior high school.
4. Work history
Not working
5. Marital status
Patient is married
6. Socio economic status
Patient lived with her family : her child and her grandchilds in a permanent house, there
is water source from PDAM, there is electricity, they can pay all they needed.
7. Family History
The patients family has not the same symptoms that he has

(patient)

Graphic of illness course

2009

2014

2015

Summary of Phsyciatric Examination

I.

General Appearance
6

II.

Counciousness

: compos mentis

Attitude

: cooperative

Motoric

: active

Facial expression

: rich of facial expression,

Verbalization

: can talk, clearly

Physic contact

: can be done, proper, long time

Attention

: good

Initiative

: good

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.
e.
f.
g.

Knowledge
Discriminative insight
Intelligence prediction
Discriminative judgment

hipotym

:
:
:
:
:
:
:

stable
controlled
echt
adequate
shallow
wide
slow

:
:
:

good
good
time, place, situation, and person
orientation is not disturbed
difficult to evaluate
not disturbed
difficult to evaluate
not disturbed

:
:
:
:

C. Sensation and perception abnormalities

1. Illusion
:
2. Hallucination
:
Acoustic
:
Visual
:
Olfactory
:
Tactile
:
Gustatory
:
D. Thought process condition
1. Speed of thought process

:
7

none
none
none
none
none
none
not too slow

2. Quality of thought process:

a. Clear and sharp
b. Incoherent
c. Sperrung
d. Hemmung
e. Flight of ideas
f. Verbigeration
g. Preservation
3. Thought condition
a. Central pattern
b. Phobia
c. Obsession
d. Delusion
e. Suspicion
f. Confabulation
g. Repulsion
h. Inferior feeling
i. Much/little
j. Feeling guilty
k. Hypochondria
l. Others

:
:
:
:
:
:
:

clear and sharp

none
none
none
none
none
none

:
:
:
:
:
:
:
:
:
:
:
:

none
none
none
none
none
none
none
none
much
none
yes
none

E. Instinctual drive and behavior abnormalities

a. Abulia
:
exist
b. Stupor
:
none
c. Raptus/impulsivity
:
none
d. Excitement state
:
none
e. Sexual deviation
:
none
f. Echopraxia
:
none
g. Vagabondage
:
none
h. Pyromania
:
none
i. Mannerism
:
none
j. Others
:
none
F. Overt anxiety

G. Reality testing ability

MULTIPLE AXIS RESUME

Axis 1.
Clinical syndrome
8

none
good in behavior, thoughts, and
Feeling

Patient difficult to fall asleep since 2008, got medication from Public Health Center then
the symptom had resolved. In 2014 the symptom came again, then she control to
psychiatry policlinic at Dr. M. Djamil General Hospital Padang, but she did not control
regulerly. In January 2015, the symptom came again. She also felt pain in her body, heaty,
weak in her leg, bone pain and stiffness at her neck. Sometimes she felt sad and want to
cry if she thinks about her children and her late husband.
Phyciatric examination
General condition: compos mentis, cooperative, active, rich of facial expression, verbalization is
can talk and clearly, good attention, good initiative, psychic contact can be done, proper, long
time.
Specific condition :
1. Affective condition : hipotym, stable, echt, shallow, wide, slow
2. Intellectual condition of function : good memory, good concentration, time, place,
situation, and person orientation is not disturbed, knowledge is difficult to evaluate,
discriminative insight and judgments is not disturbed.
3. Sensation and perception abnormalities : no illusion, no hallusinasion (auditory, visual,
olfactory, and tactile).
4. Thought process condition : clearly and sharp, coherent, hypochondria
5. Instinctual drive and behavior abnormalities : none
6. Over anxiety : none
7. Reality testing ability : good in behavior, thoughts, and feeling
Axis II. Personal disorder and mental retardation disorder
Personality disorder : none
Mental disorder

: none

Axis III. None

Axis IV. Problem with primary support group
9

Axis V. Global assessment functional

Social

: little disturbance

Daily Activity

: little disturbance.

Leisure/ recreational activity : little disturbance.

Multiple Axis diagnosis

I . F.33.01 Recurrance Mild Depresif Disorder with Somatic Symptom
II. No Diagnosis
III. No Diagnosis
IV.Problem with primary group support
V. GAF:70 - 61
Differential diagnosis
F 33.11 Recurrance Moderate Depresif Disorder with Somatic Symptom
F 38.10 Recurrance Brief Depresif Disorder
Therapy
-

Tilsan 1 x I tab @ 25 mg

B1 1 x I tab @ 50 mg

Diazepam 1 x I tab @ 2 mg (malam)

Prognosis
Clinical

dubia at bonam

Functional

dubia at bonam

Social

dubia at bonam

Suggestion for Therapy

Education to the family

10