CASE BASED DISCUSSION

NON PSYCHOTIC CASE

By :
Satriya Tjahja Hudaya

01.209.6021

Annisa Rahim

01.209.6082

Arif Driyagusta Prabowo

01.209.6088

Bagus Ayu Purnamasari

01.210.6101

Langgeng Perdhana

01.210.6205

Supervisor :
dr. Sabar Parluhutan Siregar, Sp.KJ

PSYCHIATRI DIVISION
RSJP PROF DR SOEROJO MAGELANG
PERIODE 26 AGUSTUS 18 SEPTEMBER 2015
MEDICAL FACULTY OF SULTAN AGUNG ISLAMIC UNIVERSITY
SEMARANG
2015
1

I.

II.

PATIENTS IDENTITY
Name
: Mrs. Z
Place of birth : Magelang
Born date
: December, 01st 1937
Age
: 78 years old
Address
: Sumber Agung, Secang, Magelang
Gender
: Female
Religion
: Moslem
Ethnic
: Java
Marital status : Widow
Occupation : Housewife
Education
: No formal educated
PSYCHIATRIC EXAMINATION
A. Primary Problem
The reason patient came to mental hospital is she often daydreaming at home.
B. History of Present Ilness
History of present ilness get from patient and her son on Saturday, September
12th 2015.
Name
Age
Gender
Address
Religion
Education
Occupation
Relation to patient
Long known
Intimacy

: Mr. A
: 46 years old
: Male
: Sumber Agung, Secang, Magelang
: Moslem
: Elementary school
: Farmer
: Son
: 46 years
: Close

Patient came to Clinic of Psychiatric at RSJ Prof. dr. Soerojo Magelang

because since a month ago, she often day dreaming at home. She missed her
son, Nur Hidayat that worked as a police in Jogjakarta. Her other son that
lived together with patient, Ahmad often call his brother for his mother. But,
patient still missed Nur Hidayat a lot. In the other side, Nur Hidayat can not go
home to visit her mother because of his work.
Patient often felt sad and feeling that her body have no energy to do
daily activity like washing, sweeping and so on at home. She still have an
interest to do something that makes her happy like playing with her
grandchild.

Patient also complains that she have no concentration to do something.

She feels have less appetite than before and have a sleep disturbance. She tells
that she never had a nightmare that disturb her sleep. She never felt lack of
confident. She always thinking positively and never think pesimistic. She
never think guilty and not useful and never have an idea to end her life.
Patient never have a complain like headache, palpitation, sweating, and
so on. Patient tells us that she never hear sound that other people cant hear.
She also tells she never see ghost around her home. During the symtomps
appeared, she had a lack of productivity at work.
C. History of Pass Ilness
Psychiatric
She never admitted in any mental hospital
Medical
Patient have a history of bable speaking 6 month ago. Babling
suddenly occurs when patient awaken from sleeping. Then her family
brought her to Military Hospital of dr. Soedjono Magelang to get

therapy. There is no history of Hipertension and Diabetes Melitus.

Substance abuse
Patient didnt have history of drugs, alcohol, and cigarattes
consumption

III.

PERSONAL LIFE
A. Prenatal and Postnatal Period
Patient is a fifth child. She has four older brothers, six younger brothers and
one younger sister.
B. Early Childhood (0-3 years old)
There are no valid data about prenatal history and mothers preganancy
and delivery, langht of pregnancy, spontaneity, and normality of
delivery, birth trauma, wheter the patient was planned and wanted, and

also any birth defect.

There are no valid data about feeding habits of patient (breast feeding

or bottle feeding).
There are no valid data about psychomotor like when head up (3-6
month), face down (3-6 month), sit down (6-9 month), crawl (6-9
month), walking (6-9 month), running (9-12 month), holding
something.
3

There are no valid data about psychosocial likes starting to smile when
meets other peoples (3-6 month), shocked when hear something (3-6
month), when the patient first laugh or squirm when asked to play, nor

playing claps with others (6-9 month)

There is no valid data on when patient started bubbling (6-9 month)
There are no valid data about Emotion of patients reaction when
playing, frightened by strangers, when strating to show jealousy or

competitiveness towards other and toilet training.

There are no valid data about cognitive which age the patient can
follow objects, recognizing her mother, recognizing her family

members.
There are no valid data on when the patient first copied sounds that
were heard, or understanding simple orders.

C. Intermediate Childhood (3-11 years old)

There are no valid data on when the patient began to be able to run and

play with her friends, interacted with her surrounding.

The patient has many friends and liked to play out with her neighbors
too. There was no report that the patient ever had a quarrel with her
friends.

D. Late Childhood (11-18 years old)

There was no record of her ever falling in love seriously with a male or

had any boyfriend.

Her relationship with her other siblings were also good.
The patient never complained or told her problem to her family.

E. Education History
Patients never get a formal education.
F. Occupation History
Patient work as a farmer when she was young.
G. Law History
Never has any law conflict
H. Marital History
Patient married for first time and had six children.
I. Millitary History
Never include in millitary
J. Psychosexual History
She dressed and act like a female since she was born
K. Religious
She is a Moslem and do her religious pray everyday.
4

L. Social Activity
Patient often sosializes with her neighbor.
M. Wishes
Patient wants all of her children can live happily with their family.

IV.

FAMILY HISTORY
There is no psychiatry history in her family
Genogram

: men
: woman
: having mental disorder
: patient
: passed away
-----V.

: live together

DESCRIPTION OF ILLNESS

Symptom

Time
VI.

August
2015

September
2015

MENTAL STATE
RoleA.
of Function
General Description
1. Appearance
A female, appropriate to her age, wear complete clothes.
2. State of Consciousmess
Clear
3. Connection
Attention easily attained, sustained concentration
:(+)
Attention easily attained, unable to sustained concentration: ( - )
Difficulty to attention, unable to sustained concentration : ( - )
5

4. Speech
Quantity
Quality

: decrease
: normal

B. Behaviour and Attitude

1. Behaviour
Hypoactive
Normoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Stereotypy
Mannerism
Bizzare
Command automatism
Acathysia
Tic
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
2. Attitude
Cooperative
Non-cooperative
Apathy
Tension
Dependent
Infantile
Distrust
Labile
Rigid
Passive negativism
Catalepsy
Cerea flexibility
C. Emotion
1. Mood
a. Dysphoric
b. Euthymic
c. Elevated
d. Euphoria
e. Expansive
f. Irritable

(-)
(+)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(+)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(+)
(-)
(-)
(-)
(-)
(-)
6

g. Agitation
2. Affect
a. Appropriate
b. Inappropriate
c. Restrictive
d. Blunted
e. Flat
f. Labile
D. Disturbance of Perception
1. Hallucination
a. Auditory
b. Visual
c. Olfactory
d. Gustatory
e. Tactile
2. Illusion
a. Auditory
b. Visual
c. Olfactory
d. Gustatory
e. Tactile
3. Depersonalisation
4. Derealisation
E. Thought
1. Thought of Progression
a. Quantity
Logorrhea
Talk active
Remming
Blocking
Mutism
b. Quality
Irrelevant answer
Incoherence
Coherence
Flight of idea
Confabulasion
Verbigerasion
Preservasion
Poverty of speech
Slow speech
Loosening of assosiasion
Sound assosiasion
Circumstantiality
Tangential
Neologism
Word salad

(-)
(+)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)

(-)
(-)
(-)
(-)
(-)
(-)
(-)
(+)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
7

 Echolalia
(-)
2. Content of Thought
Idea of Reference
(-)
Preocupation
(-)
Obsession
(-)
Phobia
(-)
Delusion of Persecution (-)
Delusion of Envious
(-)
Delusion of Hipochondry (-)
Delusion of magic-mystic (-)
Fantasy
(-)
Delusion of Grandiose (-)
Delusion of Control
(-)
Delusion of Influence
(-)
Delusion of Passivity
(-)
Delusion of Perception (-)
Thought of Echo
(-)
Thought Insertion
(-)
Thought of withdrawal (-)
Thought Broadcasting
(-)
3. Form of Thought
Realistic
(+)
Non Realistic
(-)
Dereistic
(-)
Autistic
(-)
F. Sensorium and Cognition
Level of education
General knowledge
Orientation of time/place/people/situation
Working/short/long memory
Writing and reading skills
Ability to self care
G. Impulse Control When Examined
Self control
Patient response to examiners question

: Low
: Good
: Good/Good/Good/Good
: Good/Good/Good
: Bad
: Good
: Good
: Good

H. Insight
Impaired insight
Intelectual Insight
True Insight
(+)
VII.

PHYSICAL EXAMINATION
A. Conciousness
: Composmentis
B. Vital sign
8

C. Head

D.
E.
F.
G.
H.

Blood pressure
: 130/80 mmHg
Pulse rate
: 84 times / minute
Temperature
: 36,60C
RR
: 20 times / minute
: normocephali, mouth deviation (-), anemic
conjungtiva (-), icteric sclera (-), pupil isocore (+),
face: melasma
Neck
: normal, no rigidity, no palpable lymph nodes
Thorax
Cor
: S1 S2 regular, murmur -, gallop Lung
: vesicular sound +/+, wheezing -/-, ronchi-/Abdomen
: Flat, abdominal wall//chest wall, normal peristaltic,
tympany sound, tenderness -, mass -, liver, spleen and
kidney not papable
Extremity
: Warm acral, capp refill <2, edema (-)
Neurogical Examinaton

Arm
Motoric Strength
Tonus
Physiological reflex
Biceps
Triceps
Pathological reflex
Hoffman
Tromner
Movement

Dextra
5
Normal

Sinistra
5
Normal

+
+

+
+

good

good

Leg
Motoric Strength
Tonus
Clonus
Physiological reflex
Patella
Achilles
Pathological reflex
Babinsky
Chaddock
Gordon
Openheim
Movement

Dextra
5
normal
-

Sinistra
5
normal
-

+
+

+
+

good

good

Cranial Nerves Examination

N I (Olfactory)
: smelling impression: good
N II (Opticus)
: isocore pupile (+/+)
N III (Occulomotorius)
:
N IV (Trochlearis)
:
OS
OD
9

N VI (Abducens)
N V (Trigeminus)
N VII (Facialis)
N VIII (Vestibulocochlearis)
N IX (Glossopharyngeus)
N X (Vagus)
N XI (Ascesorius)
N XII (Hypoglossus)
VIII.

:
: corneal reflex (+/+)
: simetric face
: hearing impression : good
: uvula in the middle (+)
: no disturbance in swallowing
: no disturbance in neck and shoulder movement
: no distrubance in tongue movement

RESUME
A patient come to the Clinic of Psychiatric at RSJ Prof. dr. Soerojo Magelang
because since a month ago, she often daydream at home. She missed her son, Nur
Hidayat that worked as a police in Jogjakarta.
Patient felt sad and feeling that her body have no energy to do daily activity
like washing, sweeping and so on at home. She still have an interest to do something
that makes her happy like playing with her grandchild.
Patient also complains that she have no concentration to do something. Patient
feels have less appetite than before and have sleep disturbance. She tells that she
never had a nightmare that disturb her sleep. Patient never felt lack of confident.
During the symtomps appeared, she had lack of productivity.
From the mental status, examination get that mood is dysphoric, affect
appropriate. She knew what been through her and she wants to be cure.

IX.

X.

SYNDROME
Mood dysphoric
Reduce energy, lackness
Depressive
Decrease of concentration
Syndrome
Sleep disturbance
DIAGNOSTIC
FORMULATION
Decrease in appetite
AXIS I
In these patient found a pattern of disorder fellings or affective.
Differential diagnosis with this patient are:
a. F32.00 Mild Depression Episode without Somatic Symptom
b. F31.3 Bipolar Affective Disorder, Episode Now Mild or Moderate Depression
Diagnostic criteria can be enforced by using diagnostic guidelines based on
PPDGJ III
F32.00 MILD DEPRESSION EPISODE WITHOUT SOMATIC SYMPTOM
DIAGNOSTIC GUIDELINES
there must be at least 2 of the 3 main

IN PATIENT
fulfilled
10

symptoms of depression such as in

mentioned.
plus at least 2 of other symptoms

no severe symptoms
all of episode duration occured at least 2
weeks
mild disability in habitual works and

Mood dysphoric

Reduce energy, lackness

fulfilled

Decrease of concentration

Sleep disturbance

Decrease in appetite
fulfilled
fulfilled
( one month)
fullfilled

usually social activity

F31.3 BIPOLAR AFFECTIVE DISORDER, EPISODE NOW MILD OR
MODERATE DEPRESSION
DIAGNOSTIC GUIDELINES
To confirm the diagnosis:
a. recurrent episode must fulfilled

IN PATIENT
fulfilled

the criteria for mild depressive

episode or moderate depresive
episode, and
b. there must be at least one

unfulfilled

episode of affective hypomanic,

manic, or mix in the past.
AXIS II
Before the illnes, patient had skizoid personality
AXIS III
Melasma
AXIS IV
Initial stressor patients is problem with primary support group (missed her son who
have not been able to go home)
AXIS V
GAF today is 80, where her symptoms is temporary, and mild disability.
XI.

MULTIAXIAL DIAGNOSIS
AXIS I
: F32.00 Mild Depression Disorder without Somatic Symptom
11

AXIS II
AXIS III
AXIS IV
AXIS V
XII.

PROBLEM RELATED TO THE PATIENT

Problem about patients biological state (organobiology)
There was an abnormality in decrease activity of norepineprine, serotonin, and

XIII.

: Personality trait skizoid.

: Melasma
: Problem with primary support group
: GAF 80

dopamine in mesolimbic
Problem about patients mental state (psychology)
The patient felt sad
The patient felt her body have no energy to do daily activity
The patient has Decrease of concentration
Problem about patients life (social)
The patient just had day dreaming along the day
The patient was a closed person before she sick.
The patient never told any of her problems to her family or friends

PLANNING MANAGEMENT
1. Hospitalization
No indication
2. Responsive Phase
The target of therapy was 50% decrease symptoms
a. Antidepressant
Selective Serotonin Reuptake Inhibitor
SSRI have little or no affinity for alpha-adrenergic histamine or
chollinergic receptor, it has low side effect rather than others
antidepressant
- Fluoxetine tab
- Initial dosage : 20mg/day
3. Remission Phase
- The target of therapy was 100% remission of symptoms
- Continue the pharmacotherapy
4. Recovery Phase
Target therapy was 100% remission of symptoms
- The patient must be taking medication regularly and control to
-

psychiatric
Family education

: tell her family about her problem and her

mental disorder and how to treat it. Its important for the family to be
support, compfort, and dont avoid her.
XIV.

PROGNOSIS
Premorbid
History of disease in the family
Marital status

: good
: bad
12

Family support
Socio-economic status (less)
Stressor
(clear)
Premorbid personality(introvert)

: good
: bad
: good
: bad

Morbid
Type of disease (affective)
Course (acute)
Organic disease (-)
Treatment response
Adherence to take medication

: good
: good
: good
: good
: good

Quo ad vitam
Quo ad sanationam
Quo ad social function

: ad bonam
: dubia ad bonam
: dubia ad bonam

REFERENCE
1. FK UNDIP. Psikiatri II Simtomatologi. Universitas Diponegoro Semarang.
2. Maslim R. Diagnosis Gangguan Jiwa, Rujukan Ringkas PPDGJ-III. Bagian Ilmu
Kedokteran Jiwa FK Unika Atma Jaya. Jakarta.2003.
3. Maslim R. Panduan Praktis, Penggunaan Klinis Obat Psikotropik. Cetakan III. PT
Nuh. Jakarta.2007.

13

GALLERY

Front view of Patients House

With patient and her family

her son, Nur Hidayat

Patients bedroom

14

The kitchen

The bathroom

15