Case Report Session

Day/Date: 25 May 2016

Major Depressive Disorder, Recurrent Episode, In

Remission

By : 1. Oksa Sukma Perdana (P.1828 A)

2. Aulia Fachri (P.1848 A)
Preceptor : dr. Yaslinda Yaunin, Sp. KJ

DEPARTMENT OF PSYCHIATRY

MEDICAL FACULTY OF ANDALAS UNIVERSITY

GENERAL HOSPITAL OF M.DJAMIL

PADANG
2016

1
I. IDENTITY OF PATIENT
Name : Mrs. M Nickname: Pit
Sex : Female
Place & date of Birthday/Age : Padang, 7th Mei 1978/ 38th y.o
Marital Status : Married
Nationality : Indonesian
Ethnics : Minangkabau
Nations : Indonesia
Religion : Muslim
Last Education : Senior High School
Jobs : Housewife
Address and Phone : Belanti, Padang 081270676946

ALLOANAMNESIS OF INFORMANT
Name : Nickname :
Sex :
Age :
Job :
Last Education :
Addressand Phone :
Relationship with Patient :
Familiarity with patient :
How long have know the patient :
Impression of the doctor about explaination of the informant :

II. HISTORY OF PSYCHIATRY

The data was taken from:

1. Autoanamnesis with patient in Polyclinic of RSUP DR M. Djamil Padang
on 24th Mei 2016 at 08.45 am

Patient came to the psychiatry polyclinic of RSUP Dr. M. Djamil Padang

on May, 24 2016 at 08.30 am

2
1. Main Cause

2. Chief Complaint
Patient often feels sad and had no passion to do activities since 6 months ago.
3. Recent Illness History
 Patient feels sad and had no passion to do activities since 15 days before
she came to hospital. Patient feels sad because of she had a fight with her
sister in law, and feels disrespected.
 Patient isolated herself in her room and diminished interest
 Patient increase in appetite
 Patient heard voices which told her that her husband will be killed since 1
week ago before she came to hospital
 Patient already had prescription from psychiatrist before, but she didn’t
take the medicine routinely
 The last few months patient didn’t hear the voices anymore, she take the
medicine routinly

4. Previous Illness History

a. Psychiatry Disorder History
 In 1998
Patient want to work to Batam, but is not allowed by her parents, it makes
she feels sad and isolated herself in her room, and then she became had no
passion to do activities and decrease in appetite. Patient attempted to
suicide by drinking a lot of medicine. Patient heard voices which told her
to looking for God, then she decided tofind God by herself at 2 am and she
left her house for a day. After she came back, her family decided brought
her to hospital and was hospitalized for a month, and she was given
medication by a psychiatrist.
 In 2001
Patients go to Batam for work, patients live in the dorm house. A few
months after the work, she had a problem with her friend in her dorm
house. It makes she feels sad and had sleep disturbing, and then the patient
is brought home for treatment. Patient already had prescription from
psychiatrist before, but she didn’t take the medicine routinely.
 In 2004
About 6 months after the marriage, she had a miscarriage, it makes she
feels sad, had no passion to do activities and increased in appetite. She was
taken to the hospital for treatment. Patient not routinely take medicine that
has previously been prescription
 In 2011

3
 Patients feels sad but didn’t remember the cause of, and patients heard
voices but can’t remember which the sound of. Patients not routinely take
her medicine

b. Medical Disorder History

History of hipertension, Head Injury, Neoplasma, seizure, HIV are
negative.

c. History of using NAPZA

History using adictive substance, alcohol, psychotropic, other addictive are
negative.

5. Family History
a) Parents : Mother and Father divorce when she was 3 years old.

b) Parents Character............. :
Father (explain by the patient) : Patient doesn’t remember
Mother (explain by the patient) : Kind, suka bergaul

c) Sibling
Patient have 2 sisters and 1 brother, patient is the 3rd child.

d) Order of sibling
1. Female (41 yo) 2. Male (39 yo) 3. Patient (38 yo)
4. Female (36 yo)

e) Character of the Sibling

Sibling Character Relationship Quality

1 Lazy, Hot Temper Not close
2 Normal Close
3 Normal Close
4
5
6
7
8

f) People live in the same house as patient

No Relation with patient Character Relationship
Quality

4
 1. Husband Hot Temper Intimate
2. Child Cheerfull, cooperatif Intimate

3. Child Cheerfull, cooperatif Intimate

g) History of psychiatry disorder, habbits, and phisical illness (in relation with
psychiatry disorder) in the family :

Anggota Psychiatry Habbits Illness

disorder
Father ….………… .…………... ………………
Mother ….………… .…………... ………………
Sibling 1 ….………… .…………... ………………
2 ….………… .…………... ………………
3 ….………… .…………... ………………
4 ….………… .…………... ………………
Grandmother ….………… .…………... ………………
Grandfather ….………… .…………... ………………
Others ….………… .…………... ………………
….………… .…………... ………………

Pedegree
( three generation)
: female, : male, : patient, : dead : : living together

5
 h) Residency History
No House House Condition
Quiet suitable Comfortable Uncomfortable
1. Parents House No No No (+)
2. Own No Yes Yes (-)
3. ………... ………. ………... ……………..

i) Others

6. Private History
a) History of Pregnancy and birth
- Pregnancy
 Patient didn’t know
- Birth History : Aterm (+) delivered by midwife (+)

b) History of childhood
Patient didn’t remember

c) Health in childhood
History of high fever and seizure are denied

d) Character in childhood
Easy going, kind,

e) School year
Elementeri Primary High Universi
School School School ty
Age 6 yo 12 yo 15 yo -
Record* Middle Middle Middle -

6
School Activity* Middle Middle Middle -

Toward friends * Kind Kind Kind -

Toward Teacher Kind Kind Kind -

Special talent Nothing Nothing Nothing -

f) Teenage years: feeling depression (+)

g) History of Job
In 2001, patient work in Batam be a labour. Conflict with Friends (+)

h) Love, Marriage, Sexual Life, and Household

 Menarche at 13 years old
 Husband :
Name : Edi Santoso
Age : 42 yo
Etnic : Jawa
Nationality : Indonesia
Religion : muslim
Education : Senior High School
Job : labourer
Social Economics : Middle
 Arranged Married (+)
 Marriage life : harmonious (-) peaceful (-) problem (+)
 Finance : Can afford Everyday needs (+), Income and
Outcome balance (+), saving (-).
 Children : grow up with parents (+)

i) Social Situation
1. Residency : Own House (+)
2. Polution : Dust (+)

j) Personality Characteristic/ Personality Disorder (for axis II)

Patient is kind, humble, often socialize outside the family.
Personality disorder : Schizoid (-), Paranoid (-), Skizotipal (-),
cyclothymic (-), Histrionics (-), Narcissistic (-), Dissosial (-), Anankastik
( -), Evade (-), Threshold (-), Dependent (-).
Personality disorder not found.

7
7. Psychosocial Stressor (axis IV)
Problem with family(+), Married (+), Problem with sister (+), problem
with partner (+)

8. Attempt on suicide (1998) because didn’t get permission to work in

Batam

9. History of law violation

There is no history of law violation

10. Religion
Patient is a moslem, problem with religion not found.

11. Perseption and family wish

Family hoping that the symptoms will improve and patient can do activity
like normal again

12. Perseption and patient wish

Patient hoping that the symptoms will improve and patient can do activity
like normal again

8
SCHEME OF DISEASE HISTORY

Year: 1998 Year: 2001 year: 2004 year: 2011 year: 2016
Age: 20 yo age: 23 yo age : 26 yo age: 33 yo age: 38 yo

she feels sad Patients go to About 6 months Patients feels sad Patient feels sad and
and isolated Batam for after the but didn’t had no passion to do
There’ work. A few There’ There’ remember the There’ activities since 15
herself in her marriage, she
s no months after s no s no cause of, and s no days before she came
room, and then had a
symp- the work, she symp- symp- patients heard symp- to hospital.Patient
she became had a problem miscarriage, it
toms toms toms voices but can’t toms isolated herself in her
had no passion with her friend makes she feels
any- any- any- remember which any- room and diminished
to do activities in her dorm sad, had no
more more more the sound of. more interest Patient
and decrease house. It passion to do
in appetite. makes she activities and Patients not increase in appetite.
Patient feels sad and increased in routinely take her Patient heard voices
had sleep medicine which told her that
attempted to appetite. Patient
disturbing .she her husband will be
suicide by didn’t take the not routinely
drinking a lot take medicine killed since 1 week
medicine
of medicine. routinely ago
Patient heard

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III. STATUS INTERNUS
 Awareness : Composmentis
 Blood pressure : 120/80 mmHg
 Pulse : Regular, strong lift, frequency 84 times
per minute
 Respiration : Regular, torachoabdominal, frequency 20
times per minute
 Temperature : Afebril
 Height : 150 cm
 Weight : 70 kg
 Nutritional status : well
 Cardiovascular system :
oInspection : Ictus cordis not visible
oPalpation : Ictus palpable around one finger medial to left
midclavicular line, 5th intercostal space
oPercussion : Up: 2nd intercostal space, left: one finger medial to left
midclavicular line, right: dextra sternalis line
oAuscultation : Normal and regular heart sound, murmurs absent
 Respiratoric System :
oInspection : Simetric statically and dynamically
oPalpation : Fremitus similar between left and right chest
oPercusion : Sonor all over the thorax
oAuscultation: Vesicular breath sound present, ronchi and wheezing absent
 Specific abnormalities : -

IV. STATUS NEUROLOGIKUS

GCS : E4M6V5
Meningeal Sign : absent
Extrapiramidal sign
 Hand tremor : absent
 Akatisia : absent
 Bradikinesia : absent
 Way of stepping : normal
 Balance : non disturbed
 Rigiditas : absent
 Motoric :
555 555
555 555
 Sensorik : well propioseptif and exteroseptif

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V. MENTAL STATE
A. General Condition
1. Awareness / sensorium: compos mentis (+), somnolence (-), stupor (-),
misty consciousness (-), confusion (-), comma (-), delirium (-), altered
consciousness (-), and etc…..
2. Appearance
 Posture: Normal (+), silence (-), weird (-), tense (-), rigid (-),
anxiety (-), looks older (-), looks younger (-), dress according
gender (-).
 Clothes: neat (+), normal (-), uncertain (-), according to the
situation (-), dirty (-), impression can take care of themselves
 Physical health: healthy (+), pale (-), fatigue (-), apathy (-), palms
wet (-), forehead sweating (-), wide eye (-)
3. Physical Contact
Able (+), can not be performed (-), natural (+), less fair (-), briefly (-),
long (+).
4. Attitude
Cooperative (+), attentive (-), blunt (-), flirting (-), hostile (-), playing
aroung(-), trying to endear (-), avoided (-), careful (-), dependent (-),
infantile (-), suspicious (-), passive (-), and others.
5. Behavior and psychomotor activity
 Gait: Normal (+), staggered (-), rigid (-)
 Ekhopraksia (-), catalepsy (-), overflow Catatonic (-), stupor
Catatonic (-), rigidity Catatonic (-), posturing Catatonic (-), cerea
flexibility (-), negativism (-), cataplexy (-), stereotypies (-),
mannerism (-),automatism (-), automatism orders (-), mutism (-),
psychomotor agitation (-), hyperactivity / hyperkinesis (-), tik (-),
sleepwalking (-), akathisia (-), compulsions (-), ataxia (-),
hipoaktivitas (-), mimicry (-), aggression (-), acting out (-), abulia
(-), tremor (-), ataxia (-), chorea (-), dystonia (-), bradykinesia (-) ,
muscle rigidity (-), dyskinesia (-), convulsi (-), seizure (-),
pyromania (-), vagabondage (-).
B. Verbalization and Speach
 Flow talks *: regular

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  Productivity talks *: regular
 Treasury *: ordinary
 Tone talks *: regular
 Volume conversation *: regular
 The contents of the conversation *: suitable
 Emphasis on conversation *: postive
 Spontaneity talks *: spontaneous
 Logorrhea (-), poverty of speech (-), diprosodi (-), disatria (-),
stuttering (-), aphasia (-), garbled speech (-)
C. Emotions
 Emotions *: stability (stable), control (adequate), echt, deep, diffrensiaton
scale (wide), the flow of emotion (normal)

1. Afective
appropriate/ match ( + ), affective Inappropriate / mismatched (-),
blunted affect (-), affective limited (-), flat affect (-), affect lability (-)

2. Mood
mood eutimik (+), mood dysphoric (-), overwhelming (expansive mood)
(-),irritable (-), mood lability (swing mood) (-), rising mood (elevated
mood / hipertim ) (-), euphoria (-), ectasy (-), depressed mood (hipotim)
(-), anhedonia (-), sorrow (-), aleksitimia (-), elation (-), hypomania (-),
mania (-), melancholia (-), La belle indifference (-), hopelessness (-).

3. Other emotions
Anxiety (-), free floating anxiety (-), fear (+), agitation (-), tension (-),
panic (-), apathy (-), ambivalence (-), abreaksional (-), shame (-), guilt (-),
impulse control (-)

4. Physiological Disorders associated with mood

Anorexia (-), hiperfagia (-), insomnia (-), hypersomnia (-), the diurnal
variation (-), decrease in libido (-), konstispasi (-), fatigue (-), pica (-),
pseudocyesis (- ), bulimia (-).

D. Mind/ Thought proccess (Thinking)

• Speed of thought process: ordinary
• Quality think the process: clear

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 1. General Disorders in Mind
Mental disorders (-), psychosis (-), the test of reality (not), thought
disorder formal (-), thinking is not logical (-), the mind is autistic (-),
dereisme (-), magical thinking (-), the process of thinking primer (-).

2. Specific Disorders in Mind

Neologisms (-), word salad (-), sirkumstansialitas (-), tangensialitas (-),
inkohenrensia (-), perseveration (-), verbigerasi (-), echolalia (-),
condensation (-), the answer is irrelevant (-), loosening of associations (-),
derailment (-), flight of ideas (-), clang association (-), blocking (-),
glossolalia (-).

3. Specific Disorders in Mind Content

 Poverty mind ( - ), Excesssive Idea ( - )
 Delusion
Bizarre delusions (-), sistematic delusions (-), delusions are in line with
the mood (-), delusions are not in line with the mood (-), delusions of
nihilistic (-), delusions of poverty (-), delusions somatic (-), delusions
persekutorik (-), delusions of grandeur (-), delusions of reference (-),
though of withdrawal (-), though of broadcasting (-), though of insertion
(-), though of control (-), Supposition jealousy / delusions of infidelity (-),
delusions blame themselves (-), erotomania (-), pseudologia fantastika (-),
religious delusions.
 preoccupation of mind (-), egomania (-), hypochondria (-), obsession (-),
compulsions (-), koprolalia (-), hypochondria (-), obsession (-), koprolalia
(-), phobias (- ) .................. .., noesis (-), unio mystica (-).

E. Perception
 Hallucinations
Non pathological: hypnagogic hallucinations (-),hipnopompik
hallucinations (-),
Auditory hallucinations (-), visual hallucinations (-), olfaktorik
hallucinations (-),gustatorik hallucinations (-), tactile hallucinations (-),
somatic hallucinations (-), lilliputian hallucinations (-), hallucinations in
line with the mood (-), hallucinations are not in line with the mood (-),

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 halusinosis (-), synesthesia (-), hallucinations (command halusination),
trailing phenomenon (-).
 Ilusion (-)

F. Dreams and Fantasy

Dreams absent
Fantasy absent

G. Cognitif and Intelectual Function

1. Time orientation (good), Place orientation (good), personal orientation
(good), situation orientation (good).
2. Attention (positive)
3. Concentration (good), calculation (good)
4. Broad general knowledge: Good
5. Mind concrete: good
6. Mind abstract: good
7. The decline of intellect : (absent), mental retardation (-), dementia (-),
pseudodemensia (-).

H. Dicriminative Insight*
Degrees VI (real emotional insight)

I. Discriminative Judgement :
 Judgment test : normal
 Social Judgment : normal

VI. An Examination By The Psychologist / Social Worker

(Text and images in the backyard)
Not done yet.

VII. Important finding conculussion

We have been examined Mrs. M, age 38 years old, female , with chief
complaint often feels sad and had no passion to do activities since 6
months ago. Mental state examination conclude that patients with neat

14
 appearance, cooperative attitude toward the examiner, verbalization is
clear and smooth, stable emotions, affective appropriate, eutimik mood.
From the thought process and mind normal, there’s no general and
spesific disoreder of thought process, and for disorder content of thought,
delusions absent. There’s no hallucinations and illusions. The orientation is
normal and discrimnative insight and judgment is normal.

VIII. Multiaxial diagnosis

Axis I : F33.4 Major Depressive Disorder, Reccurent episode, In
Remission
Axis II : No Diagnoisis
Axis III : No diagnosis
Axis IV : problem with primary support group
Axis V : GAF 80-71

IX. Differential Diagnoses of Axis I

F33.0 Major depressive Disorder, Reccurent Episode, Mild

X. Treatment
A. Pharmacotherapy
Haloperidol 1x1.5 mg
Fluoxetin 1x10 mg
Merlopam 1x0.5 mg

B. Psychotherapy
1. Patient
- Support psycotherapy

Giving empathy to the patients. Identifying trigger factors and help

solve the problems

- Psychoeducation

15
 Help patients to learn more about their disorder , so patient has a
more effective ability to recognize the symptoms, and immediately
get help.
2. The family:
Psychoeducation about
- Patient disorder

- Therapy

- Providing support and attention to the patients

XIV. PROGNOSIS
Point Good Not good
Onset Adult √ -
Onset of time Clear √ -
Family Support Not good - √
Marital status Married √ -
Positive symptom None - -
Symptom of mood Depression √ -
disorder
Precipitating factor Clear √ -
Sosial withdraw None √ -
Sign neurologis None √ -
disorder
Many relaps Exist - √
episode
Others disease None √ -

Quo et vitam : Bonam

Quo et fungsionam : Bonam
Quo et sanctionam : Bonam

XV. DISKUSI/ ANALISIS KASUS

Based on anamnesis, the history of clinical course of this patient was
founded that there is significant changes in behavior pattern and feeling clinically
and it causes disability in function, working and social. Therefore, based on
PPDGJ III, it can be concluded that the patient have mental disorder.

16
 Based on interview, patient often feels sad and had no passion to do
activities since 6 month ago. Patient isolated herself in her room and increased in
appetite. Patient heard voices which told her that her husband will be killed since
1 week ago before she came to hospital. Patient already had prescription from
psychiatrist before, but she didn’t take the medicine routinely. Patient had often to
hospital for treatment with chief complain feels sad, diminshed interest, decreased
in appetite. Patient had suicide history. But the last few months patient feels
happy and dind’t hear the voices anymore. The elements above meet the criteria
for anxiety disorders based on PPDGJ III, so diagnosis for the axis Major
Depressive Disorder, Reccurent episode, In Remission (F33.4).
From the patient's personal history, patient is kind and humble, there is no
personality disorders in patients. Based PPDGJ III, for the diagnosis of
personality disorder, there must be at least three characteristics that are found.
Thus, the diagnosis on axis II is no diagnosis.
From the history of medical illness, patients have never experienced a
head trauma and other diseases that can cause physiological dysfunction in the
brain before showing mental disorder, therefore, organic mental disorders (F00-
F09) can be removed.
From psychosocial, patient had promblems from the family. So in these
patients psychosocial and environmental stressor or Axis IV there is had problems
with primary support group .
For axis V, the patient feels the symptoms temporary and there is a mild
disorder in relation to the social and jobs, so based on the assessment GAF
(Global Assessment Of Functilainning) Scale, right now the patient is at a value
80-71.

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 Lampiran 1. Kutipan wawancara psikiatri
Pertanyaan
pagi buk, perkenalkan kami
dokter muda di siko buk,
awak dokter muda Aulia,
ciek lai dokter muda Oksa.
Lai buliah wak mananyo
tentang keadaan ibuk?
Sia namo ibuk?
Bara umua ibuk kini?
Tanggal bara ibuk lahia tu?
Kini ko hari a buk?tanggal
bara kini bu?
Dima ibuk tingga?
Ba perasaan ibuk kini?
Jo sia ibuk kamari?pakai a
kasiko buk?
Ndak diaantaan suami buk?
Ado apo ibu kasiko?a nan
taraso buk?
Ubek untuk a tu buk?
Kalau buliah tau dek a tu
ibuk taibo?
Dek a ibuk diberangi?
Jawaban Interpretasi
Io Buliah Komposmentis
kooperatif
Marfitriani Orientasi personal
baik
38 tahun
Tanggal 7 mei 1978 Orientasi waktu
baik
Hari selasa tanggal 24 mei
Di belanti Padang Orientasi tempat
baik
Kini wak sanang se nyo Mood eutim
dokter, bahagia
Jo anak pakai kendaraan
umum
Indak, suami karajo, ndak
nio maantaan awak doh
Kontrol nio ambiak ubek,
santa lai ubek habis
Patang tu awak barubek dek
maleh se manga-manga tu
taibo se hati ko
Awak diberangi dek suami
dan dingaannyo kecek awak
doh
Macam-macam, patang ko
dek wak maleh manga-
manga tu samba itu ka itu se
ndak do variasi,berang-
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 berang nyo
Maleh-maleh ko dek a Kiro-kiro 6 bulan yang lewat
awalnyo buk? adiak suami wak ko ka
manikah,diadoan di rumah
kami, tu awak bantu-
bantu,tapi adiak ko ndk do se
bantuak mehargoi awak,tu
wak caritoan ka
suami,tadanga di adiak
ko,basilisiah paham jadinyo,
tu sadiah awak
jadinyo,manguruang diri se
ibuk di kamar lai,maleh
manga-manga
Tu ba kecek apak buk? apak ko diam diam se ndak
do didanganyo wak bacarito
Tu a yang ibu lakukan lai? Tu diam diam se di kamar, Halusinansi
tapi sudah tu ado ibuk auditorik
tadanga suaro suaro yang
mangecekan kalau suami
awak ka dibunuah,tu
batelepon suami ko taruih,
Sia yang mangacekan tu Ndak do nampak sia yang
buk?tau ibuk sia? mangecek, tadanga se

Pacayo ibuk pas tu bu Patang tu io pacayo wak

suaro-suaro tu?
A kecek apak ibuk Dibaok awak barubek,
mandanga-danga tu buk? sabalumnyo alah jo pernah
dapek ubek, tapi maleh
minumnyo
Berarti iko lah barubek yang Lah yang kalimo, partamo
kabara ko buk? waktu tahun

19
 1998,2001,2004,2011,2016
A se yang mambuek ibuk Macam-macam, tahun 1998 Kriteria depresif,
dibaok barubek? awak sadiah dek ndak depresif berulang
diizinan pai ka batam
karajo,tu manguruang diri di
kamar,maleh makan,tu
pernah cubo bunuah diri, tu
tadanga suaro-suaro
manyuruah cari Allah
Tahun 2001ado masalah jo
kawan kost tu sakik wak liak
Tahun 2004 dek keguguran
tu sadiah,maleh manga-
manga,
2011 ndak takana dek a
sadiah
Tu 6 bulan yang lalu
Suaro-suaro tu ibu pacayo jo Dulu pas sakit tu pacayo,
yang dikecekannyo? kini dek lah mendingan sadar
wak itu ndak do sabanayo
doh
Kini masih ado suaro-suaro Ndak do lai doh,sejak teratur
tu buk? ambo makan ubek ndak do
mandanga lai doh
Rancak tu buk memang Io dokter, kini lai amuah Discriminative
harus teratur ibuk makan awak makan ubek teratur insight tidak
ubek yo buk,bia capek ibuk terganggu
sehat
Ibuk kalau ado masalah tu Dulu lai,patang ko dek ndak
lai carito-carito ka yang didangaan,maleh ibuk carito
lain? lai
Kalau ada kebakaran Wak padamkan Discriminative
dirumah ibuk, a yang ibuk judgement tidak

20
karajoan? terganggu
apak kalau malam bisa Bisa, jago jam 4, shalat
lalok? tahajud
Kalau nafsu makannya ba Lamak makan kini,naiak
kini buk? barek badan
Ado pertanyaan buk? Tidak dok
Rancaknyo buk kalau nan Io dokter
taraso di hati ibuk kurang
sanang,caritoan ka suami
atau keluarga ibuk yang
lain, ajak suami ngawanan
kontrol barubek buk
Makasi banyak yo buk Samo-smo dokter

21
Lampiran 2. Tulisan dan Gambar pasien

22