NON-PSYCHOTIC

Pembimbing:
dr. Sabar Parluhutan Siregar, Sp.KJ

FAKULTAS KEDOKTERAN
UNIVERSITAS TANJUNGPURA
2018
IDENTITY

Patient’s Identity Relative Identity

• Name : Mrs. L • Name : Mrs. W
• Age : 29 years old • Age : 60 years old
• Gender : Female • Gender : Female
• Address : Kedu, Temanggung • Address : Kedu, Temanggung
• Religion : Moeslem • Occupational : Housewife
• Ethnic : Java • Relation : Mother
• Marital Status : Widow • Intimacy : Close
• Occupational : Work in
Factory
• Education : Senior High
School
• Date of Entry : October 13rd,
2018
• Date of examination :
October 13rd, 2018
ANAMNESIS

The reason why patient was bring to the

hospital
Patient bring to hospital because of pacing, confused and
restless
ANAMNESIS
Present story of patient illness :

• Alloanamnesis
From alloanamnesis with her mother found that patient
was bring to mentol hospital Prof. dr. Soerojo Magelang
because the patient often paced home since 2 week ago.
Patient confess confusion to their mother. The mother
said patient suddenly read books about religion. Patient
more lazy to work and do anything, have trouble sleeping
and lack of appetite. Patient have married at 22 years old
but divorced at 24 years old.
ANAMNESIS
Present story of patient illness :

• Autoanamnesis
From autoanamnesis, patient said she’s fine and not sick
just confused and anxious after listen a lecture on
television that said islam was divided into several groups
and there only a few groups can go to heaven and
patient be confused about which group would go to
heaven. Patient said they were anxious when listen
lecture “do you want god reveal all your sins” until the
patient get a bad dream because feels he has many sins.
The patient feel him self tired, cannot do anything, feel
lazy and head feel heavy.
ANAMNESIS
History of Illness :
• Psychiatric disorder :
There is no history of patients’s psychiatric illness
• General medical illness disorder :
There is no history of patients’s medical illness disorder
• Substance abuse :
History of smoking (-), alcohol use (-), drug abuse (-)
ANAMNESIS
History of Personal Life :

• Prenatal and Perinatal

There is o valid data.
• Early Childhood Phase :
There is no valid data
• Intermediate Childhood Phase :
There is no valid data
• Late Childhood and Teenager Phase :
There is no valid data
ANAMNESIS
• Adulthood Phase
- Education : Senior High School
- Occupational : Patient work in factory
- Marital staus : widow
- Criminal : patinet has no criminal history
- Social activity : Patient haven’t a close friend since she
get a sick. She is close to her sibling and her parent.
- Psycosocial : Patient have a normal relationship with
her parent and sibling.
- Current situaton : Patient lived with her mother

Family History :
There is no history of same symptoms in her family
PEMERIKSAAN FISIK
Status Internus
KU : Baik TD : 118/68 mmHg RR : 20 x/menit
Kesan : Compos mentis HR : 108 x/menit T : 36,8OC

Kepala Normocephal

CA(-/-), SI (-/-), pupil reguler bulat isokor 3 mm/3 mm, refleks cahaya (+/
Mata
+)

Mulut Bibir sianosis (-), mukosa bibir kering (-), atrofi papil lidah (-)

Leher Bentuk simetris, ↑JVP (-), pembesaran KGB (-)

Statis, bentuk dada simetris, kelainan kulit (-). Dinamis, gerakan paru
Inspeksi simetris, tidak ada gerakan paru yang tertinggal, penggunaan
otot bantu pernapasan (-)

Paru Palpasi Fremitus taktil paru kanan = paru kiri, nyeri tekan (-)

Perkusi Sonor dikedua lapang paru

Suara napas dasar: vesikuler (+/+). Suara napas tambahan: wheezing
Auskultasi
(-/-), ronkhi (-/-)
PEMERIKSAAN FISIK
Status Internus
Jantung Inspeksi Iktus kordis tidak terlihat
Palpasi Iktus kordis tidak teraba
Perkusi Batas kanan jantung: SIC IV linea parasternal dextra
Pinggang jantung: SIC III linea parasternal sinistra
Batas kiri jantung: SIC V linea midclavicularis sinistra
Auskultasi S1/ S2 reguler, murmur (-), gallop (-)
Abdomen Inspeksi Distensi (-), sikatrik (-)
Auskultasi Bising usus (+) 6x/menit
Perkusi Timpani
Palpasi Supel (+), hepar dan lien tidak teraba, nyeri tekan (-),
massa tidak teraba
Ekstremita Akral hangat, CRT <2”, edema (-/-)
s

Kesimpulan dalam batas normal

PEMERIKSAAN FISIK
Status Neurologis
Motorik : Tonus normal, koordinasi gerakan baik, eutrofi,
kekuatan motorik 5/5/5/5
Meningeal sign : negatif
Refleks fisiologis : +/+
Refleks patologis : -/-
Sensorik : Dalam batas normal

Kesimpulan dalam batas normal

MENTAL STATUS EXAMINATION
General Appearance :
A female, 29 years old, appropriate to her age, good for self
care, were complete and clean clothes, look stabil.
Orientation (P/T/P/S) : Good
Psycis contact : Present, euitable, constant.
Behavior : Hypoactive
Verbal :
- Quantity : decreased
- Quality : normal
Mood : Dysporia
Affect : Depresive
Perception :
- Hallucination (-)
- Illusion (-)
- Depersonalization (-)
- Derealization (-)
MENTAL STATUS EXAMINATION
Thouhgt of Process :
- Quality : Coheren
- Quantity : Remming
Thouht of Content :
Idea of suspicion
Thought Form :
Non-realistic
Insight : Impaired insight
Attention Connection :
Attention not good, unable to sustained concentration
MENTAL STATUS EXAMINATION
Sensorium and Cognitive :
- Level of education : bad
- General knowledge : bad
- Orientation : moderate
- Woring/Short/Long memory : moderate
- Ability to read and write : low
- Ability to independent : moderate
Impulsive control when examine :
- Self control : enough
- Patient respons : enough
DIAGNOSIS
Depressive syndrome :
- Depresive affect
- Anenergy
- Anhedonia
- Idea of feeling guity
- Sleep disturbed
- Decrease appetite
- Anxious
- Restless
- Head fell heavy

DIAGNOSIS BANDING
F32.1 Moderate Depresive Disorder
F41.1
DIAGNOSIS MULTIAKSIAL
AKSIS I : F32.1 Moderate Depresive Disorder
AKSIS II : No diagnosis
AKSIS III : No diagnosis
AKSIS IV : Trouble with psycosocial
AKSIS V : 60-51 currently
MANAGEMENT PLANNING
Patient doesn’t need to hospitalized
Maintenance therapy : Fluoxetin 20 mg/24 hours
Haloperidol 1 mg/12 hours
Psycotheray :
- Behavior management
- The patient need family support
- Explain that environment, neightborhood, family
situation assocaited to the disorder.
PROGNOSIS
Quo ad vitam : Dubia ad bonam
Quo ad functionam : Dubia ad bonam
Quo of sanactionam : Dubia ad bonam
THANK YOU