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NON-PSYCHOTIC
Supervisor : dr. Sabar Parluhutan Siregar, Sp.KJ
▸ Name : Mrs. NH
▸ Age : 55 years
▸ Gender : Woman
▸ Address : Dompyong, Temanggung
▸ Ethnic : Javanese
▸ Religion : Moslem
▸ Education : Senior High School
▸ Job : Housewife (Restaurant owner)
▸ Marital Status : Married
▸ Date of examination : 5th May 2018
“
Identity (Alloanamnesis)
▸ Autoanamnesis :
The patient was going to polyclinic of Psychiatric
Hospital Prof. Dr. Soerojo Magelang because she
has an over anxiety about being sick since about 6
months ago.
Cont..
▸ Psychiatry disorder:
• Patient always control routinely in polyclinic of RSJS since
October 2017
• Patient alwyas consume her medications
Sertraline 50 mg 1-0-0
Trifluoperazine 5 mg 0-0-1
Lorazepam 2 mg 0-0-1
Cont..
▸ Occupational
After graduated from senior high school, patient work as a model
with Basuki Abdullah for two years, than she run the restaurant
▸ Marital Status
Patient has beed married 3 times, last time she divorced 2014
Cont..
▸ Religion
Patient is a moslem and doing prayer 5 times a day routinely
▸ Family Relationship
Patient is the youngest child from 7 siblings, she dominantly close
with her mother and her big brother who has beed passed away
Cont..
▸ Responsibility in medicine
Patient is consume her medicine routinely
FAMILY HISTORY OF ILLNESS
▸ Psychiatric Disorder
Patient’s 4th big sister also have symptomps like
her
▸ General Medical Illness
Patient’s mother and 5th big brother had passed
away because of stroke and her mother also had
hypertension
GENOGRAM
Legends:
Patient
Female
Male
Die
Physical Illness
Psychiatry Illness
Live Together
Divorced
Symptoms
Okt Mei
2017 2018
Role of Function
▹ Head : normocephali
▹ Eyes : conjungtival anemi-/-,
icterous sclera -/-
▹ Nose : secrete -/-
▹ Ears : normotia/normotia, secrete -/-
▹ Mouth : sianosis (-)
▹ Neck : lymphnode enlargement (-)
Thorax
In normal range
Abdomen
In normal range
Urogenital
In normal range
Ekstremitas
In normal range
PEMERIKSAAN NEUROLOGIS
▸ GCS : E4 V5 M6
▸ Kaku kuduk : Tidak ditemukan
▸ Saraf kranialis I - XII : Tidak ada penemuan
bermakna
▸ Refleks fisiologis : Tidak dilakukan pemeriksaan
▸ Refleks patologis : Tidak dilakukan pemeriksaan
▸ Sensorik : Tidak dilakukan pemeriksaan
▸ Motorik : 5 5
5 5
PEMERIKSAAN
STATUS MENTAL
a. Deskripsi Umum
Sikap dan tingkah laku : kooperatif, normoaktif
Tanda jenis kelamin : perempuan sesuai usia
Pakaian dan kerapihan : rawat diri baik dan berpakaian
Perhatian dengan pemeriksa : mudah ditarik mudah dicantum
a. Afek
Keserasian : apropriate
Konsistensi : stabil
a. Mood : eutimik
a. Bentuk pikir : Realistik
b. Gangguan persepsi : disangkal
c. Isi pikir :
d. Progresi pikir
Kuantitatif : normal
Kualitatif : normal
a. Orientasi W/T/O/S : baik/baik/baik/baik
Tilikan diri :5
FORMULA DIAGNOSIS
▸ Psikoterapi
▹ Pengenalan terhadap penyakitnya, manfaat pengobata, cara
pengobatan dan efek samping pengobatan
▹ Memotivasi pasien gar minum obat secara teratur dan rajin
kontrol setelah pulang dari perawatan
▹ Membantu pasien untuk dapat kembali melakukan aktivitas
sehari-hari secara bertahap
▹ Membantu pasien untuk lebih mendekatkan diri kepada Allah
TERAPI
▸ FARMAKOLOGI
Sertraline 50 mg 1-0-0
Trifluoperazine 5 mg 0-0-1
Lorazepam 2 mg 0-0-1
36
PROGNOSIS