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CASE BASED DISCUSSION

NON-PSYCHOTIC
Supervisor : dr. Sabar Parluhutan Siregar, Sp.KJ

Oleh : Andi Yusrizal 20174011081


Itqi Rahmatul Laila 20174011157
Rizka Ulfatin Arifah 20174011170
Patient Identity

▸ 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)

There was no valid data from the alloanamnesis


ANAMNESIS
MAIN PROBLEM
The patient had an over anxiety about being sick and
suggested by an internist to check to psychiatry
HISTORY OF PRESENT ILLNESS

▸ 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..

▸ The patient feels anxiety when


▸ She thinks about her illness especialy
hypertension
▸ Holding back bowel movement
▸ Satiety
▸ Wake up late
Cont..

▸ What happens when the patient feels anxiety


▸ Feels easily surprised
▸ Difficult to sleep
FAKTOR PREDISPOSISI
▸ Trembling
▸ Pounding
▸ Fatigue
▸ Heavy breath
Cont..

The patient has been hospitalized because her blood


pressure reach 190/100 mmHg. The other
examination beside her blood pressure was normal,
but she start afraid about her illness since that

August October October


2017 2017 2017
Patient was brought to the emergency departement
because she complaint about dyspneu, pounding,
headache, and trembling. Her blood pressure at that
time is 220/120 mmHg. Her ECG result and other
examination results are normal.

August October October


2017 2017 2017
The patient feels anxious because she got drugs
once in a day and thinks it’s not enough. The patient
consulted to psychiatry and diagnosed as general
anxiety disorder and always control her illness

August October October


2017 2017 2017
HISTORY OF PAST ILLNESS

▸ 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..

▸ General medical illness


• Patient has diagnosed with hypertension since August
2017 and has been hospitalized three times
• High fever, seizure, head trauma, allergy, or another
chronic disease denied.
▸ Substance abuse
There’s no history of smoking, alcohol use, or drug abuse
HISTORY OF PERSONAL LIFE
▸ Prenatal and Perinatal Phase
• The patient was the seventh child of seven children
• There’s no valid data in patient’s prenatal aspect (ANC, age,
condition when pregnant such as hypertension, weight gain
when pregnant of immunization status before and when
pregnant)
• There’s no valid data in patient’s perinatal aspect (APGAR
score, difficultines during labor or patient’s condition during
birth, and immunization status
• Early Childhood (0-3 years old)
• There’s no valid data in patient.

• Masa kanak akhir (11-18 th)


Pasien semakin menutup diri setelah mengalami gangguan
jiwa saat kelas 1 SMP dan memutuskan untuk berhenti
sekolah.
ADULTHOOD
▸ Education
Patient graduated from senior high school with quite good score.

▸ 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

▸ Current living situation


Patient lives alone at his home

▸ 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..

▸ Understand and self awareness


Patient feels that her mental problem is not a normal condition

▸ 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

CURVE PROGRESSION OF ILLNESS


PHYSICAL
EXAMINATION
INTERNAL STATUS

▸ Conciousnes : Compos mentis E4V5M6


▸ Vital Sign
Blood Pressure : 130/90 mmHg
Heart Rate : 72 x/minute
Respiration Rate : 22 x/menit
Temperature : 36,5° C
HEAD

▹ 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

Sindrom yang didapatkan dari pemeriksaan :


▸ Sindrom Cemas
▹ Rasa gemetar
▹ Tidak bisa diam
▹ Nafas pendek/berat
▹ Jantung berdebar-debar
▹ Kepala pusing/rasa melayang
▹ Mudah terkejut/kaget
▹ Sukar tidur
DIAGNOSIS

▸ F41.1 (Generalized Anxiety Disorder)



F41.1 Gangguan Cemas Menyeluruh

Pedoman Diagnostik Menurut PPDGJ – III Kondisi Pada Pasien


a. Penderita harus menunjukkan anxietas sebagai gejala primer yang berlangsung
hampir setiap hari untuk beberapa minggu sampai beberapa bulan, yang tidak
terbatas atau hanya menonjol pada keadaan situasi khusus tertentu saja (sifatnya
“free floating” atau “mengambang”)
b. Gejala-gejala tersebut biasanya mencakup unsur-unsur berikut:
c. Pada anak-anak sering terlihat adanya kebutuhan berlebihan untuk ditenangkan
Terpenuhi
(reassurance) serta keluhan-keluhan somatik berulang yang menonjol
d. Adanya gejala-gejala lain yang sifatnya sementara (untuk beberapa hari),
khususnya depresi, tidak membatalkan diagnosis utama Gangguan Anxietas
Menyeluruh, selama hal tersebut tidak memenuhi kriteria lengkap dari episode
depresif (F32.-). Gangguan anxietas fobik (F40.-), gangguan panik (F41.0), atau
gangguan obsesif-kompulsif (F42.0)
DIAGNOSIS MULTIAKSIAL

▸ Axis I : F 41.1 Gangguan cemas menyeluruh


▸ Axis II : Z03.2
▸ Axis III : Hipertensi
▸ Axis IV : Masalah berkaitan kondisi kesehatan
▸ Axis V : GAF 80-71
TERAPI

▸ 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

No. Faktor-Faktor Pada Pasien Baik Buruk


Faktor Premorbid
1. Riwayat gangguan jiwa pada keluarga Ada 
2. Status pernikahan Cerai 
3. Dukungan keluarga Ada 
4. Dukungan sosial Ada 
5. Status Ekonomi Menengah Keatas 
6. Stressor Ada 
37

No. Faktor-Faktor Pada Pasien Baik Buruk


Faktor Morbid
8. Onset 54 tahun 
9. Jenis penyakit GAD 
10. Onset usia < 20 tahun 
11. Respon terapi Baik 
12. Kepatuhan minum obat Patuh 
13. Penyakit Organik Tidak ada 
38

Ad Vitam : dubia ad bonam


Ad Fungsionum : dubia ad bonam
Ad Sanationam : dubia
39
DAFTAR PUSTAKA

Muslim, Rusdi. 2007. Penggunaan Klinis Obat Psikotropik. Bagian


Ilmu Kedokteran Jiwa FK Unika Atma Jaya. Jakarta

Muslim, Rusdi,. 2003. Buku Saku DIAGNOSIS GANGGUAN


JIWA.Jakarta: PT Nuh Jaya
THANKS

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