CASE BASED

DISCUSSION NON-
PSIKOTIK
dr. Sabar Parluhutan Siregar,
Sp.KJ
FAUZAN ABDURRAHMAN (20184010076)
DIAN ALIFIA KURNIA W. (20184010078)
LUTHFIYYA SYAFIQA T. (20184010088)
PATIENT’S IDENTITY

Name : Mrs. L
Gender : Female
Age : 36 years old
Address : Candimulyo
Religion : Mosleem
Ethnic : Javanese
Education : Bachelor
Occupation : in Agriculture Departement
Marriage status : Married
Date of admitted : 7th August 2018
Date of examination : 12th August 2018
FAMILY IDENTITY

Name : Mrs. P
Age : 61 years old
Gender : Female
Address : Candimulyo
Religion : Mosleem
Education : Bachelor
Occupation : Pensionary
Relation : Mother
Intimacy : Close
Long know : Since birth
 Complaint

“ Patient came to Psychiatry Clinic of Mental Health

Hospital Prof. Dr. Soerojo Magelang because she felt
sad
“

ANAMNESIS
Obtained in Psychiatry Clinic (7th August 2018) and patient`s house (12th August 2018)
 ALLO-
• She was a very patient person, but
suddenly she changed ANAMNESIS

• Often felt sad and cried because of

work and family condition

• She often scolded her children

 AUTOANAMNESIS

Her third son was born

She was married with with caesarean
her husband process
September
2005 2010 2011 2015 2017
She started working Her first twin children She was on her 3th
near her house was born prematurely pregnancy of her 4th children
with caesarean and she moved to a new
process workplace further from her
house and she started to get
irritated easily. She was
worried about her pregnancy
condition
 Her 4th son was born with She came to Psychiatry Clinic
caesarean process. Her husband because she felt sad and
came home to take care of her guilty to her children because
and their children for one month, she felt that she couldn’t
the he had to back to Jakarta taking care of her children
well
January April June August
2018 2018 2018 2018
She had to leave from her She had to join a
work because of her bad training program for 21
condition for 3 months and days in Soropadan on
she also had a bleeding Ramadhan month
spots. She lost her appetite
History of Past Illness
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Psychiatric Illness
01 This is the first time experiencing
something like this.

General Medical Illness

02 There’s no history of high fever, sizure, head trauma, DM,
hypertension, allergy or any other serious illness.

Substance Abuse
03 She didn`t have history of smoking and
illegal drugs.
 History of Personal Life
Prenatal
Her mother said that when she was pregnant, she was on a good condition.
Mrs. L was the second child of 3 children. There’s no valid data in patient prenatal
aspect (ANC, age, condition such as hypertension, weight gain, etc.)

Perinatal
There`s no valid data in patients perinatal aspect (APGAR Score, difficulties during
labor or patients condition during birth, and immunization status)
Early Childhood Phase
Psychomotor
There’s no valid data in patient’s psychomotor aspect, such as tilting body,
supine to prone, crawling, sitting, standing, walking, holding with his hand,
scoop up the object or pining up the object
Psychosocial
There’s no valid data in patient’s psychosocial aspect such as showing intention
when seeing object, knowing his family members or pointing what she want
without crying
Communication
There’s no valid data in patient’s communication aspect such as bubbling,
cooing, making sound without meaning, telling 2-3 syllables without meani
ng or calling his family
Early Childhood Phase
Emotion
There’s no valid date in patient’s emotion aspect such as happy when playing, smile
while seeing interact object, frightened by strangers, starting to jealousy or
competitiveness with others and toilet training
Cognitive
There’s no valid data in patient’s cognitive aspect such as copying sound that he heard
for the first time, understand simple words and learning the shape/function of objects

Parenting
There’s no valid data about how her parents treated her, giving breast milk or formula,
how long it was given or when he was given side dish
 Intermediate Childhood Phase
Psychomotor
There’s no valid data in patient’s psychomotor aspect, such as throwing ball, wearing a cloth by him
self, ride bicycle or involved in any kind of sports
Psychosocial
There’s no valid data in patient’s psychosocial aspect such as started to implement “initiative vs guil
t” concept by planning activities, making their own choices, accomplishing the task, facing challeng
e or keep trying when fail. There’s no valid data about how patient started to implement “industry vs
inferiority” concept by having competitive spirit, responsibility, do teamwork, knowing a good and ba
d things, studying problem and solving problems
Communication
Patient was able to speak sentences clear enough and she was talkactive

Emotion
She had no bad feeling towards her family
 Intermediate Childhood Phase
Cognitive
There’s no valid data in patient’s cognitive aspect such as knowing the function of object
s, knowing the synonym/antonym of word, or grouping some object based on their same
characteristic
Parenting
There is no valid data about how patient’s parents guide him to learn or when his first tim
e at school he doing by herself or accompany even waited by his parents. There’s no vali
d data about whether the patient is still watering on bed or not, or whether when eating, h
e still given by her parents or no
Progress in School
Patient was a smart student. She always got a good grade in her class. Although she was
n`t study harder but she could get a good grades.
Late Childhood Phase
Psychomotor
Patient was rarely doing sports

Psychosocial
That’s no valid data about her patients started o implement “identity vs role function” con
cept by starting to dress his own up with his own clothes. Trying to act rebel to show his
identity, brawling to show her power, or going out with his friends.

Communication
Patient can communicate very well
Late Childhood Phase
Emotion
Patient felt happy when she was gathered with her family and her friends.

Cognitive
there’s no valid data on cognitive aspect such as ability to identify, formulative, and solv
e the problems with his reasoning.

Parenting
there’s no valid data about how patients parent treat him such as checking his acade
my progress, giving atentions to his achivement at school, guide him to learn giving a
n advice for him or treating him at home.
Adulthood Phase
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Educational
01 Patient final education was a bachelor degree

Occupational
02 Patient work in agricucltural department since
2005

Marital Status
03 Patient is married
Adulthood Phase
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Criminal
04 Patient has no criminal history

Social Activity
Patient lives with her parents and her children.
05 Her husband works in Jakarta. Her
relationshp with her neighbour is god

Current Situation
Patient is currently works near Borobudur
06 which is far from her house. She left her
children to her parents when she went to
work
 Family History
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Psychiatry Illness
01 There`s no history of the same symptoms in her
family.

General Medical Illness

02 There`s o history of high fever, seizure, head
trauma, allergy, other chronic disease, etc

Substance Abuse
03 There`s no history of smoking, alcohol use or
drug abuse.
G
E
N
O
G
R
A
M
 Physical Examination
A. Consciousness: Compos Mentis

B. Vital Sign
1. Blood pressure
120/80 mmHg, right arm, sitting position, appropriate cuff size

2. Pulse
85 x/minute, regular, filling and tention enough

3. Temperature
36,5oC, axilla

4. Respiratory rate
20 x/minute, regular, symetric, abdominothoracal type
Head
• Normocephally (+), trauma (-), deformity (-)
Eye
• Anemic conjungtiva (-), icteric sclera (-), pupillary isochor (-), red eye (-/-)
Nose
• Deformity (-), discharge (-) septal deviation (-) symmetric (+) trauma (-) inflammation (-) nasal flare
(-)
Ear
• Deformity (-), discharge (-) inflammation (-) cerumen (+/+)
Mouth
• Dry mouth (-) hyperemic mucous (-) normal teeth (-) T1-T1 muscle paralysis (-)
Neck
• Lymph node enlargement (-) skin decolorization (-) JVP (n) mass (-) scar (-)
Skin
• Cyanotic skin (-) turgor(-)
Cor
• I: deformity (-) scar (-) ictus cordis (-)
• P: ictus cordis is palpable on ICS V linea midclavicula sinistra
• P: cor enlargement (-)
• A: s1-s2 regular (+) heart murmur (-) s3 gallop (-)
Lung
• I: simetrical movement (+) use of acessory muscles (-) trachea deviation (-)
• P: tactile fremitus (-) movement (-) pain (-)
• P: sonor
• A: vesicular sound (+/+) ronchi (-/-) wheezing (-/-) crepitation (-/-)
Abdomen
• I: swelling (-) scar (-) inflammation (-)
• A: intestinal murmur (n) 1x/minute
• P: tympanic sound (+) in 13 points, liver span (n) 8 cm, spleen enlargement (-)
• P: Superficial pain (-), deep pain (-) liver and spleen are palpable (-) skin turgor (n)
 Extremity Superior Inferior
Edema - -
Cyanotic - -
Look Deformity -
Inflammation - -
Scar + on left hand -
Acral Warm Warm
Pitting edema - -
Feel
Capillary refill time <2 seconds <2 seconds
Pain - -
Limited movement + on left hand -
Move Active - -
Passive - -
Tremor + -
General Appearance
Body posture Normal
Abnormal movement tremor, rigid
Walking style Normal, slightly lame

Motoric Upper limb Lower limb

Muscle tone + +
Trophy Eutrophy Eutrophy
Power of movement 5 5
Clonus - -
ROM Normal Normal
Involuntary movement + +

Sensoric Upper limb Lower limb

Fine touch Normal Normal
Crude touch Normal Normal
Vibration Normal Normal
Pain Normal Normal
Temperature Normal Normal
 Physiological Reflex
Upper Limb
Biceps Reflex (+/+)
• Identify the location of the biceps tendon
• Allow the arm to rest in patient’s arm lap forming on angle sight > 90 of the
elbows
• Make sure the muscles is completely relaxed
• Placed your thumb/ middle finger of contralateral hand to the patient ( which hold
patient arm) on the tendon
• Ask ptient to look on the other side while you stroke the hammer

Triceps Reflex (+/+)

• Identify the location of the triceps tendon
• Make sure the muscles completely relaxed
• Placed your thumb/ middle finger of contra-lateral hand to the patient ( which hold
patient arm) on the tendon
• Ask patient to look on the other side while you stroke the hammer
 Patological Reflex
Upper Limb
⁃ Hoffman reflex (-/-)

• Tapping the nail and flicking the terminal phalanx of the

middle or ring finger
• Positive result showed by flexion of the terminal phalanx of
the thumb

⁃ Trommner reflex (-/-)

• Patient finger is practically flexed while you gently hold their

finger, tapping of volar aspect of the middle finger
• Positive result showed by flexion or abduction all four finger
 Physiological Reflex
Lower Limb
Patella reflex (+/+)

• After tapping the hammer on patella tendon, leg is

normally extended

Achilles reflex (+/+)

• After tapping the hammer on achilles tendon on dorsal

maleolus, foot is normally dorsoflexi
 Patological Reflex
Lower Limb
Babinsky refleks (-/-)

• The reflex occur upon strolling of the plantar side with blunt object, positive
result show by dorsoflexion of the hallux

Chaddock reflex (-/-)

• The reflex occur upon strolling over the lateral malleolus with blunt object,
positive result show by dorsoflexion of the hallux

Gordon reflex (-/-)

• Squeezing the calf muscles, positive result show by dorsoflexion of the hallux
 Patological Reflex
Lower Limb
Oppenheim reflex (-/-)

• Irritation downward of the medial side of the tibia, positive result show by
dorsoflexion of the hallux

Rosalimo reflex

• Percussion of the ball of the foot, positive result show by plantarflexion of

the hallux

Schaffner reflex

• Squeezing / pinching the achilles tendon, positive result show by dorso-

flexion of the hallux
 Meningeal Sign
Kernig sign (-)
• Patient was supine with straight extremity behind,
• Tight flexed towards hip and kness 900, extended lower leg while hold the knee normally can
reach up to 1350 derajat
• Positive result showed by pain or resistance before reach 1350
Brudzinsky I
• Patient relax and supine with staright extremity beside,
• Examiner hold patient’s head and flexed till chin reach sternum,
• Neck stiffnes (+) if chin can’t reach sternum,
• Brudzinsky 1 (+) : while flexed the neck, also for lower leg
Brudzinsky II(-)/ brudzinsky contralateral leg sign
• Patient was supine with straight extremity beside,
• flexed of one leg with straight position maximally,
• positive result showed by flexion of contrallateral leg
 Meningeal Sign
Brudzinsky III (-)
• Patient was supine with straight extremity beside,
• Press patient’s cheeks/infraorbital bilateral with hand,
• Positive result showed by flexion of both hands
Brudzinsky IV
• Patient was supine with straight extremity beside,
• press os pubic of patient with hands,
• positive result showed by flexion of both legs
Cerebellum function examination
• heel 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 (-)
Cranial nerve Examination Check up result
right left
N. I Smelling test good
N. II Pupil size Round, d = 3 m Round , d = 3 m
m, isokor m, isokor
Visus Not inspected Not inspected
Color bind Not inspected
Funduscopy Not inspected
N. III, IV, VI Position of eyeb OS located in th OS located in th
alls e middle e middle
Eyeball moveme There are no obstacles to the right, rig
nt ht top-down, left, top-down
Nystagmus - -
Diplopia -
Light reflex DLR+, IDLR + DLR +, IDLR +
N. V Motoric Symetric
Sensoric Good
Cranial nerve Examination Check up result
right left
N. VII Motoric occipitofrontal Good Good
Motoric orbicularis okuli Good Good
Motoric orbicularis oris Good Good
N. VIII Hearing test Good
Balance test
N. IX, X Tongue tasting ⅓ posterior Good
Swallowing test
Vomiting test
N. XI Shrug Good
Turned
N. XII Tongue movement Good, no lateralization
Disartria (-)
 Mental State Examinaton
Date : 12th August 2018

General appearance

• a 36 years old woman, appropriate to his age, look normoweight, good self-care/
grooming, wears a complete woman’s clothes.

Orientation of:

• People: good
• Time: good
• Place: good
• Situation: good
• Consciousness: clear

Physical Contact

• Present/absent, equitable/inequitable, constant/non-constant

Behaviour
• Hypoactive
• Normoactive • Automatism • Psychomotor agitati
• Hyperactive • Automatism of com on
• Echopraxia mand • Compulsive
• Catatonia • Bizarre • Ataxia
• Active negativism • Mutism • Mimicry
• Cataplexy • Acathysia • Aggressive
• Stereotypy • Tic • Impulsive
• Mannerism • Somnambulism • Abulla
Attittude

• Cooperative • Infantile
• Non cooperative • Labile
• Indifferent • Rigid
• Apathy • Passive negativism
• Tension • Stereotype
• Dependent • Catalepsy
• Passive • Cerea flexibility
• Excited
VERBAL
1. Quantity: increase/ normal/ decrease
2. Quality: normal/ decrease
Mood Affect
Dysphoric Appropriate
Eutymic Inapproriate
Elevated Broad
Euphoria Restrictive
Irritable Blunted
Agitation Flat
Labile
 Perception
Hallucination (-) Illusion (-)
Auditory Auditory
Visual Visual
Olfactory Olfactory
Gustatory Gustatory
Tactile Tactile
Somatic Somatic

Depersonalization (-)
Derealization (-)
 Thought Progress

Quantity Qualities
Logorrhea Irrelevant answer Confabulation Verbigeration
Blocking Coprolallia Loosening associat Perseveration
ion
Remming Incoherence Neologism Sound associatio
n
Mutism Flight of idea Circumstantiallity Word salad
Talk active Poverty of speech Tangentiallity Echolallia
 Thought Content
• Idea of reference
• Preoccupation
• Obsession
• Phobia
• Fantasy
• Delusion of persecution
• Delusion of reference
• Delusion of envious
• Delusion of hypochondri
ac
• Delusion of magic • Thought of withdrawal
mistic • Thought of broadcasting
• Delusion of grandiose
• Delusion of control
• Delusion of religion
• Delusion of influence
• Delusion of passivity
• Delusion of suspicion
• Idea of suicidal
• Idea of suspicion
Thought Form
• Realistic
• Non realistic
• Dereistic
• Autistic
• Dereallistic
• Form at thought
• Illogical thinking
Insight
• Impaired insight
• Intelectual insight
• True insight
Attention connection
• Attention easily attracted, able to sustained concentration
Sensorium and Cognition
• Level of education: good
• General knowledge: enough
• Orientation: good
• Working/short/long memory: good
• Ability to read and write: enough
• Ability of thought: enough
• Ability of independent: enough

Impulsive control when examine

• Self control: good
• Patient respond: good
 0
4
HDRS
0
2 =9
0
2
0
0
0 0
0
0
0
1 0

0
0 0
 Resume
ANAMNESIS

• A 36 years old woman came to hospital because she felt sad. She
felt sad because she started to be irritated easily after her
workplace was moved further from her house. She also felt guilty
because she couldn’t take care of her children well. She lost her
concentration and made her late in finishing her job. She also lost
her appetite as well

MENTAL STATUS

• Mood : irritable
• Afek : inapproppriate
• HDRS : 9
 MINOR
Decreased concentration
Guilty
Loss of appetite

MAJOR
Mood Dysphoric Syndrome Only a little difficulty in work and
Anenergy depression social activitities that are ussually do

Symptoms on patient
 Differential
Diagnose

F32.1 Moderate
Depressive
Disorder
• Axis I F43.2 Adaptive Disorder
• Axis II No diagnosis yet Multiaxial
• Axis III No diagnosis yet
• Axis IV Problem with job
Diagnose
• Axis V
– GAF when admitted and examination :
GAF 50-41 ( severe symptoms, severe dissabilities)
 Organobiologic Psychologic Social problem

• No specific physical • mood dysphoric • Energy: slightly

or disease disorders • decreased decrease
are found that affect concentration • Workplace moved
the patient's mental • Felt Guilty • Anxiety of pregnancy
state. Allegedly there • Post partum
• Lost appetite
is a neurotransmitter
imbalance that • irritable
requires
pharmacotherapy.

PROBLEMS
Psychotherapy Planning
Cognitive behavioral therapy
Family education Management
Physical activity
Pharmacotherapy
Fluoexetine tabs 1x20mg
Haloperidol tabs 1x0.5mg
 PROGNOSIS
Point In Patient Prognosis
Premorbid
Family history Absent Good
Marital status Married Good
Family Support Present Good
Economical status Normal Good
Stressor Present Good
Premorbid personality None Good
Morbid
Age onset Adulthood (36 years old) Good
Type of disease Depression Good
Onset Acute Good
Organic disease None Good
Response of therapy Response Good
 PROGNOSIS

• Ad Vitam : Ad bonam
• Ad Functionam : Dubia ad bonam
• Ad Sanationam : Dubia ad bonam
Foto Rumah
Pasien
 Thank you
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