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KEDOKTERAN DAN

ILMU KESEHATAN

CASE BASED DISCUSSION

Supervisor
dr. Sabar Parluhutan Siregar, Sp.KJ
Disusun Oleh:
Maheksa Hayu Purnama (20184010004)
Reza Setyono Ashari (20184010022)
Lutfiana Arifah (20184010034)

Kepaniteraan Klinik Departemen Ilmu Kesehatan Jiwa


Rumah Sakit Jiwa Prof. Dr. Soerojo Magelang
KEDOKTERAN DAN
ILMU KESEHATAN

Patient Identity
• Name : Mrs. T
• Born of Date : September , 27st 1975
• Age : 43 years old
• Address : Tegalrejo, Magelang
• Gender : Female
• Religion : Islam
• Ethnics : Javanesse
• Marital status : Married
• Occupational : Maid
• Education : Elementary school
• Date of entry : January, 6th 2019
• Date of examination: January, 8th 2019
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Family Identity
• Name : Mr. S
• Gender : Male
• Age : 45 years old
• Address : Magelang
• Occupational : Seller
• Relationship : Husband
• Intimacy : Closed
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ANAMNESIS
History was obtained by alloanamnesis and autoanamnesis

Reason why patient was brought to hospital  Patient pushed


her mother in law until her mother in law felt down while
carrying patient’s baby, yesterday.
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Alloanamnesis
Pushed her
Patient was
mother in law
advised when she
until felt down
was cooking rice She got angry
while her mother
with excessive
in law carrying
water
her baby

Beside that, patient also:


1. She often seen talking to herself
2. She often seen walking back and forth, she was scared
3. Sleep irregularly, she sometimes just sleep for an hour all
night
4. The patient used to be socially active in the neighborhood,
but now she spend lots of her time alone
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5 months before come to hospital


(4 months 3rd pregnancy)

She also
easily got
Patient often tired when
Patient was daydreaming working
shocked and and spend her
felt scared time alone
Doctor told
that she must
do caesarean
surgery
USG: breech
presentation
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At the labor time (17 days 7 days before come to the


before come to the hospital
hospital) • The patient started to hear
• Patient could give birth the sound of ambulance’s
without caesarean siren and whispers, but
• The baby was not well people around her couldn’t
enough, so the baby must hear that sound
been treated intensively • She often looked walking
• Find out her baby condition, back and forth while saying
the patient felt so sad and ‘istighfar’
guilty • She saw someone wearing
white coat like a doctor and
someone looks like her
husband. But her family
couldn’t see them.
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She doesn’t like to be advised, so
she pushed her mother in-law. But
Autoanamnesis after that, she regret it

The patient doesn’t


know why she was When she was alone, she
taken to the asylum sometimes could hear ambulance’s
siren and whispers that insulting
She said that she feel guilty and sad because her. One of that whispers is say that
she believes she has a lot of mistakes and sins. she is a bad mother. Everytime she
That thought is like echoing inside her head. hears ambulance’s siren, she
remembered the moment when
She feels urge to she gave birth
apologize to everyone
whom she met
She ever seen a men wearing white
She feels confuse of her condition, and coat just like a doctor and a person
everytime she feels like that she feels urge for who’s like her husband. She said
walking back and forth while saying istighfar. that they just standing still and
staring blankly to her. She doesn’t
But she doesn’t feel like feel like they are chasing after her
something is controlling herself or want to to hurt her
or told the patient to do so
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HISTORY OF PAST ILLNESS


Psychiatric
• No history
History
Allergic
• No history
• Head trauma (-) history
General • Hypertension (-)
medical • DM (-)
illness • Brain infection (-)
Alcohol and • Alcohol (-)
• Epilepsy (-) NAPZA • NAPZA (-)
Substance • Smoking (-)
abuse • Drug (-)
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HISTORY OF PERSONAL LIFE


Prenatal and Perinatal
No valid data of:
1. Patient’s mother ANC history, age and condition when she
was pregnant
2. Her appetite and weight gain, immunization status
3. Mother’s history of pre-eclamsia, hypertension and other
morbid condition.
4. Mother’s history of mental illness before, during or after
pregnancy.
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Standard Physical Examination of


ANC (Ante Natal Care)
• Weight and height gain
• Blood pressure and exam
• Nutritional status
• Find presentation of the fetus & fetal heart rate
• Toxoid tetanus immunization status
• Zinc tablet and Fe tablet
• Lab examination if needed
• Case therapy (counseling & treatment)
• Counseling labor planning, complication, prevention,
contraception
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Fundal Height
 40 weeks: fundus drops below 38
weeks. Levels as presenting part drops
into pelvis
 36-38 weeks: fundus usually right up
under sternum
 32 weeks: 2 cm under proc
xyphoideus
 26 weeks: between umbilics & pro
xyphoideus
 24 weeks: 2 cm under umbilicus
 20 weeks: at umbilicus
 14-16 weeks: 2 cm under umbilicus
 12 weeks: fundus just above pubic
bone
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Early childhood phase (0-3 years old)


There is no valid data on :
• Patient’s psychomotor aspect (supine/prone, crawling, sitting, standing, walking, hold
hand, scoop up the object, holding pencil or pulling up object)
• Patient’s gross motoric aspect (standing with one leg in 5 second, riding tricycle)
• How patient start to implement ‘trust vs mistrust’ concept by knowing the quality of
her relationship with her mother
• How patient start to implement ‘autonomy vs shame and doubt’ concept by knowing
the freedom to do will
• Patient’s communication aspect such as making a sound without meaning, telling 2-3
syllables or calling his family
• Patient’s emotion (happy when playing, smiling while seeing interactive object,
frightened by stranger, starting to be competitive or jealous with others)
• Patient’s cognitive aspect (Copying sound that was heard for the first time,
understanding simple words and learning the shape/ function of an object)
• Patient’s parent parenting style whether she was given breastmilk or formula
• How patient start to implement ‘Anal phase’ concept by toilet training.
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Plaget’s theory of cognitive development


Age Cognitive development
Birth -2 mo Use inborn motor sensory reflexes (sucking, looking to interact and
accommodate to internal world.)
2-5 mo Primary circular reaction : coordinates activities of own body and five sense
(e.g. sucking thumb) reality remain subjective doesn’t seek stimuli outside
of his usual field or display curiosity
5-9 mo Secondary circular reaction = speaks out new stimuli in the environment
start both to anticipate consequences of own behaviour and to act
purposefully to change the environment, beginning to intentional behavior
9 mo- 1 y.o Shoe preliminary sign of object permanence, has a vague concept that
object exist apart from itself, plays peek a boo, imitates novel behaviour.
1 y.o- 18 mo Tertiary circular reaction = seeks out new experiences, new novel
behaviour
18 mo- 2 y.o Symbiotic though; use symbolic representation of event and object show
sign of reasoning (e.g. use one toy to reach to for and get another.)
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Intermediate Childhood Phase (age of 4 – 11)


NO VALID DATA ON:

 Psychomotor aspect (throwing a ball, wearing cloth by himself, ride a bicycle or


involved in any kind of sports)
 Psychosocial aspect “Initiative VS Guilt” concept by planning activities and
making their own choices. Initiative versus guilt is the third stage of Erik Erikson's
theory of psychosocial development (age of 3-6).
 Psychosocial aspect “Industry VS Inferiority” concept by having responsibilities,
doing team works, separating what’s good and what’s bad, studying and solving
problems. Erikson's fourth psychosocial crisis, involving industry vs. inferiority
occurs during childhood (age of 6-12).
 Communication aspect (Mentioning her name, age and asking/ answering
question expression on opinion, speaking in sentences, telling story and speaking
clearly enough for stranger to understand)
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• Patient’s emotional aspects (showing what she wants, knowing her mistake,
crying or happy, if it was appropriate / inappropriate with what she want,
showing an empaty to her friend, describing her feeling or starting to develop
negative self image)
• Cognitive aspect (knowing functions of objects and synonyms/antonyms of
words. He had difficulties in learning. “Phallic stage” concepts by being curious
about human’s body, such as a curiosity of why there are differences between
male’s and female’s body parts. The “phallic stage” is the third stage of
psychosexual development in Freudian psychoanalysis (age of 3 – 5 or 6). At this
stage, children become aware of anatomical sex differences. There is no valid
data on patient’s cognitive aspect such as knowing function of object, knowing
the synonym or antonym of word, or grouping some object based on their same
character
• How patients parent suit her to learn or when her first time at school. There’s no
valid data about whether the patient still watering on her bed or not, or wether
she is still assisted when eating or not.
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Late Childhood and Teenage Phase (age of 12–18)


NO VALID DATA ON:
• Psychomotor aspect (playing the game or some sport)
• Psychosocial aspect: started to implement ‘identity vs role’ concept by starting
to dress her own up with her own clothes. During this stage, adolescents search
for a sense of self and personal identity, through an intense exploration of
personal values, beliefs, and goals. Erikson suggests that two identities are
involved: the sexual and the occupational.
• Communication aspect (expressing his personal opinion in conversation giving
on advise & debate)
• Emotion aspect (worrying about grade, appearance, and popularity)
• Cognitive aspect (ability to identify, formulate, and solve problems with their
own reasoning). Children become able to reason not only about tangible objects
and events, but also about hypothetical or abstract ones.
• Patient academic progress (patient achievements, patient attitude with teacher
and her friend, her seniors and juniors, or her activities at school)
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Adulthood Phase (age 18 – now)


• Occupational : Housemaid
• Marital status : Married
• Military history: She never join military activities
• Education : Elementary school
• Religion : Islam
• Social activity : Her relationship with his family and neighbors is good.
• Criminal history: There was no criminal history recorded.
• Current situation: Patient live with her husband and her 3 children

 Psychiatric disorder  no history of any psychiatric disorder


 General Medical Illness  no history of fever, seizure, chronic disease,
allergy or any other serious illness in her family
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GENOGRAM
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DESCRIPTION OF ILLNESS
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PHYSICAL EXAMINATION
KEDOKTERAN DAN
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• Consciousness
Level of consciousness based of GCS remain
Compos mentis 15-14
Apatis 13-12
Delirium 11-10
Somnolen 9-7
Stupor 6-4
Coma 3

(E) Eye Response


Score (V) Verbal Response (M) Motoric Response
(Opening)
1 No Response No Response No Response
2 To Pressure (to pain) Incomprehensible sounds Abnormal Extension
3 To Sound (to speech) Inappropriate Abnormal Flexion
4 Spontaneously Confused Flexion withdrawal from pain
Oriented to time, place,
5 - Moves to localized pain
person
6 - - Obeys commands
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Respiratory Pattern
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Blood Pressure
Blood Pressure
Sistole BP (mmHg) Diastole BP (mmHg)
Classification

Pre Hypertension 120-130 Or 80-89

Stage 1 Hypertension 140-159 Or 90-99

Stage 2 Hypertension >= 160 Or >=100

Pulse
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PHYSICAL EXAMINATION

• INTERNAL STATUS
1. Conciousnes : Composmentis (GCS E4V5M6)
2. Blood Pressure : 165/105 mmHg (stage 2 hypertension)
3. Heart Rate : 116x/minute, regular, filling and tension enough (N)
4. Respiration Rate : 18x/minute, regular, systemic, thoracoabdominal type
(N)
5. Temperature : 36.5°C, axilla (N)
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PHYSICAL EXAMINATION
• Head : normocephali (+), trauma (-), deformity (-)
• Eyes : conjungtival anemi (-/-), icterous sclera (-/-), pupil isochor (+), red eye (-/-)
• Nose : deformity (-), secrete (-/-), septal deviation (-), trauma (-), inflammation (-),
• Ears : normotia (+/+), secrete (-/-), inflammation (-), cerumen (+/+)
• Mouth: sianosis (-), drymouth (-), hyperemic mucous (-), Tonsil T1/T1, muscle
paralysis (-)
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Red Eyes Diagnostic Pathway
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Neck masses due to benign masses


A : parotid gland tumor (pleomorphic
adenoma, warthin’s tumor)
B : parotid gland tumor (pleomorphic
A adenoma, warthin’s tumor) glomus
jugulare (paraganglioma)
C : submandibular gland tumor (pleomorphic
B adenoma, warthin’s tumor)
D : lymphaneitis
C E : branchial cleft anomallies, carotid body
humors (paraganglioma) schwamiomas
D F : thyroglossal duct cyst, laryngocele
E FG G : thyroid cysts, goiter

Neck masses due to cancer


A :cancer of nasopharynx, paratiroid
gland
B :cancer involving the submandibular
gland, anterior 2/3 tongue, floor of
mouth gums, or oral cavity mucose
C :lips cancer
D :cancer of the nasopharynx, posterior
scalp, ear, temporal bone, skull base
E :cancer of the oral cavity, pharynx,
A tonsil, base of tongue, larynx
C F :cancer of thyroid, pyriform sinuses,
B upper esophagus, lung
G :cancer of thyroid
E FG
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• Thorax
Cor
Inspection :deformity (-) scar (-) ictus cordis (-)
Palpation :ictus cordis is palpable on ICS V linea midclavicula sinistra
Percution :cor enlargement (-)
Auscultation:s1-s2 regular (+) heart murmur (-) s3 gallop (-)
Lung
Inspection :simetrical movement (+) use of accessory muscles (-) trachea
deviation (-)
Palpation :tactile fremitus (-) movement (-) pain (-)
Percution :sonor
Auscultation: vesicular sound (+/+) ronchi (-/-) wheezing (-/-) crepitation (-/-)
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• Abdomen

Inspection : swelling (-) scar (-) inflammation (-)


Auscultation : intestinal murmur (n) 10/minute
Percution : tympanic sound (+) in 13 points, liver span (n) 8 cm,
spleen enlargement (-)
Palpation : Superficial pain (-), deep pain (-) hepar and lien is
palpable (-) skin turgor (n)
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Extremity
• General Appearance
Body posture Normal

Abnormal movement -

Walking style Normal


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Extremity
Motoric Upper limb Lower limb

Tonus + +

Trophy Eutrophy Eutrophy

Power of movement 5 5

Clonus - -

Rom Normal Normal


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Extremity
Sensoric Upper limb Lower limb

Fine touch Normal Normal

Crude touch Normal Normal

Vibration Normal Normal

Pain Normal Normal

Temperature Normal Normal


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NEUROLOGICAL EXAMINATION
UPPER LIMB (PHYSIOLOGICAL REFLEX)
• Biceps Reflex (+/+)
• Triceps Reflex (+/+)

UPPER LIMB (PATOLOGICAL REFLEX)


• Hoffman Reflex (-/-)
• Trommer Reflex (-/-)
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NEUROLOGICAL EXAMINATION
LOWER LIMB (PHYSIOLOGICAL REFLEX)
• Patella Reflex (+/+)
• Achilles Reflex (+/+)

LOWER LIMB (PATHOLOGICAL REFLEX)


• Babinsky Reflex (-/-)
• Chaddock Reflex (-/-)
• Gordon Reflex (-/-)
• Oppenheim Reflex (-/-)
• Rosalimo Reflex (-/-)
• Schuffner Reflex (-/-)
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NEUROLOGICAL EXAMINATION
Meningeal Sign
 Kernig sign (-)
 Brudzinsky I (-)
 Brudzinsky II (-)
 Brudzinsky III (-)
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NEUROLOGICAL EXAMINATION
Cerebellum Function Examination
• Heal to toe/ tendem gait test(normal)/ walking on staright line
• Romberg test (+) stand with closely foot and close eyes for 30
minutes
• Whist romberg test (+) stand with heel to toe foot and close eyes
for 30 minutes
• Dysdiadochokinesis (-) clap with alternating the palmar and dorsal
surface of the hand as fast as possible and repeat with other hand
• Finger to nose (-) nose to nose (-) finger to finger (-)
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Cranial Nerve Examination


• There is no significant findings in cranial nerve examination
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MENTAL STATE EXAMINATION


General Appearance
• A female. 43 years old, appropiatte to her age, bad
self-care.

Orientation
• People : good
• Time : good
• Place : good
• Situation : good

Psychic Contact
• Present (+) / absent
• Equitable (+)/ unequitable
• Constant (+) / non constant
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Behavior and Atitude


 Autistic
 Behavior
• Normoactive (+)  Achatysia
• Hypoactive  TIC
• Hyperactive  Somnambulism
• Echopraxia  Compulsive
• Catatonia  Apraxia
• Active negativism  Mimicry
• Cataplexy  Aggressive
• Mannerism  Impulsive
• Automatism  Abulia
• Bizarre
 Agitate (+)
• Mutism
 Ataxia
• Stereotype
 Ambivalensia
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 Attitude
 Cooperative (+)  Passive negativism (+)
 Non cooperative  Catalepsy
 Indifferent  Flexibilitas cerea
 Apathy  Excited
 Tension

 Dependent

 Passive

 Infantile

 Labile

 Rigid
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Verbal
• Quantity : increased / normal / decreased
• Quality : normal / decreased
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Mood and Affect  Affect


 Mood • Appropriate (+)
 Dysphoric (+) • Inappropriate
 Exphansive • Broad
 Eutimic
• Restrictive (+)
 Elevated
• Blunted
 Euphoria
• Flat
 Irritable
• Labil
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Perception

 Depersonalization (-)  Illusion


 Derealization(-)  Auditory

 Visual
 Hallucination
 Olfactory
• Auditory (+)
 Gustatory
• Visual (+)
 Tactile
• Olfactory
 Somatic
• Gustatory
• Tactile
• Somatic
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Thought Progress
 Quality:  Neologysm
 Quantity:  Irrelevant  Circumstantiality
 Logorrhea
 Coprolalia  Tangentiality
 Talkactive
 Flight of idea  Vebrigeration
 Blocking
 Poverty of speech (+)  Persevation
 Remming (+)
 Sound asosiation  Word of salad
 Mutism
 Ecolali
 Confabulation
 Loosening assosiation
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 Idea of suspicion
Thought of Content:
 Delusion of control
• Idea of reference
 Delusion of religion
• Pre-occupation (+)
 Delusion of influence
• Obsession  Thought of echo (+)
• Phobia  Thought of insertion
• Fantasy  Thought of withdrawal
• Delusion of persecution  Thought of broadcast
• Delusion of reference  Delusion of passivity
• Delusion of fault (+)  Wisdom of greatness
• Delusion of enviour
• Delusion hypochondriac
• Delusion of magic-mistic
• Delusion of sin (+)
• Idea of succidal
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Thought of Form :
• Non-realistic (+)
• Dereistic
• Autistic
• Derealistic
• formatthought
• Illogical thinking
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Insight :
• Impaired insight (+)
• Intellectual insight
• True insight
Attention Conection :
• Attention easy to attracted, not able to sustained concentration

Sensorium and Cognitive :


• Level of education : poor
• General knowledge : poor
• Orientation : enough
• Working/short/long memory : enough
• Ability for read and write : enough
• Ability to thought : enough
• Ability to independent : poor

Impulsive Control when Examine


• Self control : enough
• Patient respond : enough
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SUMMARY (RESUME OF SIGNIFICANT FINDING)


• Spend lots of time alone
• Looks and feel sad
Five months • Get tired easily
ago • Sometimes just sleep for hours all night
• Often daydreaming

• Often looked walking back and forth while saying


‘istighfar’
• Talks to herself
Seven days • Started to hear ambulance’s siren and whispers
ago • Ever saw men like a doctor and her husband
• Feels guilty and sad
• Believes she has lots of sin and fault

A day ago • Patient pushed her mother in-law


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Mental state examination


• General Appearance : Female, 43 years old, appropriate to his age, bad self-care
• Physical contact : Present, equittable, constant
• Behavior : Normoactive
• Attitude : Cooperative, passive negativism
• Verbal : Quality and quantity are decreased
• Mood : Dysphoric
• Affect : Appropriate, restrictive
• Perception : Auditory and visual hallucination
• Thought of Progress : Quantity: Remming, Quality: Poverty of speech
• Thought of Content : Pre-occupation, delusion of fault, delusion of sin, and
thought of echo
• Thought of Form : Non-Realistic
• Insight : Impaired insight
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SYNDROME
• Auditory Hallucination
• Visual Hallucination
Schizophrenia • Thought of progress: Poverty of speech
Syndrome • Thought of content: thought of eco
• Thought of form: non-realistic
• Impaired insight

•Mood: dysphoric
•Affect: restrictive
Depression
•Remming
Syndrome
•Delusion of fault
•Delusion of sin
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Differential diagnosis
F 32.3
• Episode of severe depression with
psychotic symptoms
F 25.1
• Schizoaffective disorder, depressive type
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Axis I
• F 32.3 Episode of severe depression with psychotic
symptoms

MULTI AXIAL Axis II


DIAGNOSE • R46.8 Axis II diagnosis is pending
Axis III
• I00 – I99: Circulatory system disease (hypertension)

Axis IV
• Pregnancy and baby birth

Axis V
• GAF 30 – 21
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List of problems
• Biological : neurotransmitter imbalance. Especially at the
mesolimbic pathway that cause + symptoms
• Psychological : hallucination auditoric, hallucination
visual, delusion of fault, delusion of sin, remming, poverty of
speech.
• Sociological : self-withdrawal, low self confidence, ADL
decreased
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Pharmacological and non-pharmacological


therapies
Advised to be hospitalized, because she is at risk of harming themselves
and other people.
Pharmacological therapy
• Response phase (IGD and UPI) : 50% decreased of syndrome.

Due to her dominant positive psychotic symptoms, she will be given :


Haloperidol injection 5mg/12 hours, intramuscular

Due to her anxiety psychotic-accompanying symptoms, she will be


given
Diazepam 10 mg/24 hours, intramuscular
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• Maintenance therapy
Due to her dominant positive psychotic symptoms, she will be
given
Haloperidol tab 5 mg/12 hours per oral

Due to her dominant retarded depression symtoms she will be


given
Fluoxetine tab 20 mg/24 hours per oral in the morning

If during treatment with haloperidol, extrapyramidal symptoms


appeared. She will be given:
Trihexyphenidyle tab 2 mg/24 hours per oral
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Non-pharmacological therapy
• Psycho-education for patient and family, include
– Explanation about the illness of the patient
– The drug that must be consumed by the patient
include benefits, how to consumed, and the side
effects.
– Motivate the patient and family for came to control in
time
– Motivate the patient to re-do daily activities gradually
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PROGNOSE
PREMORBID
• History of psychiatric disorders in the family (none) : Good
• Marital status (married) : Good
• Family support (lack of treatment compliance support) : Good
• Socioeconomic status (enough) : Good
• Stressor (clear) : Good
• Premorbid personality (extrovert) : Good
MORBID
• Onset age : 43 y.o (Good)
• Type of disorder : Psychotic (Bad)
• History of disease : None (Good)
• Organic disorder : None (Good)
• Insight : impaired (Bad)
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• Ad vitam : dubia ad bonam


• Ad functionam : dubia ad bonam
• Ad sanationam : dubia ad bonam
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