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I.

PATIENT IDENTITY
Name : Mr. A
Age : 24 years old
Sex : Male
Address : Magelang Regency
Ethnic : Javanese
Religion : Islam
Education : Senior High School
Occupation : Farmer
Marital state : Not Yet Married

II. PSYCHIATRIC HISTORY


Interview was conducted on 10th of April 2017 in the patients previously-
mentioned residency. Information on his illness chronology was mostly taken
from her Uncle.

Name : Mr. P
Sex : Male
Age : 44 yo
Address : Danurrejo
Ethnic : Javanese
Religion : Islam
Occupation : Labour
Marital State : Married
Relation : Uncle

Case Based Discussion Non-Psikotik 1


Fakultas Kedokteran Universitas Tanjungpura
Autoanamnesis was conducted on 10th of April 2017 in the patients previously-
mentioned residency.

A. Chief Complaint
The patient has been feeling morose since 4 months ago.

B. History of Present Illness


Alloanamnesis
The patient has been feeling morose since 2 years ago, according to
patient and his uncle. Patients uncle said complaint is accompanied with
memory loss, sleepless, lack of concentration and anxiety. teraction with her
family and her neighbors has been decreasing. Prior to the onset of the
symptom, she was still able to do daily choirs such as cooking, doing the
laundry and cleaning the house. According to her husband, this complaint
started when she found out her husband has been having an affair with one of
their neighbors, an accusation he did not deny. Since then, she has locking
herself in her room more often. She also has been crying and getting angry at
her husband more often than usual. Her emotion gets uncontrollable every
time she sees the neighbor her husband has been having an affair with.

Autoanamnesis
The patient stated that he had been feeling fatigued when he was working
in Taiwan. He feels useless unmotivated to do anything, which she stated is
caused by the disappointment towards her husband. She has been feeling
uncomfortable sleeping and frequently wakes up from her night sleep. She
stated that she has resigned to her problems and has been spending most of her
time praying.

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Fakultas Kedokteran Universitas Tanjungpura
C. History of Past Illness
1. Psychiatric History
There is no history of psychiatric illness.
2. History of medical illness
- Head injury (-)
- Convulsion (-)
- High fever (-)
- Allergy (-)
- Diabetes mellitus (-)
- Trauma in right knee 6 years ago
3. Drugs and Alcohol Abuse and Smoking History
There is no history of drugs & alcohol abuse or history of smoking.

D. Personal History
1. Prenatal and Perinatal History
Patient is the oldest son. Patient only had one brother. During pregnancy
her mother was in a good condition. Her mother gave birth to him in their
house with a midwife.
2. Early Childhood (Birth through age 3 years)
Patient was taken care of his parents since his birth, and was breastfed
exclusively for about one and a half years, with complete history of
immunization. His developmental growth such as starting to sit by herself,
crawl and walk was similar to other kids her age. He was a healthy and
lively boy.
3. Middle Childhood (ages 3 to 11 years)
Patient started his primary education when he was 6 years old. Around this
time, he started to interact with other kids his age and was decisive in
doing so. His academic performance wasnt relatively good in the primary
school. He was failing grades for two times because he help his parents
business when he was in primary school.

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Fakultas Kedokteran Universitas Tanjungpura
4. Late childhood (Puberty through adolescence)
Patient finished junior and senior high school very well without failing a
grade.
5. Adulthood
a. Sexual History
Patient realizes that he is a man and has been dressing up and acting as
a man. He is attracted to women.
b. Marital and Relationship History
Patient is not yet married.
c. Occupational History
Patient helped his parents business when she was in primary school.
Patient started to work again after graduating. Patient work in Taiwan
as labour in plastic factory for 11 months. Patient stop working there
because the work intensity is to much to handle. The workers work
from 8 a.m to 12 a.m, while the time to rest were 12 p.m to 1 p.m, 5 p.m
to 6 p.m, and 10.00 p.m to 10.30 p.m. Patient feels the work is too hard,
so that he stoped from the work. Now, he works as a farmer and a
mechanic.
d. Education History
Patient graduated from senior high school.
e. Religion History
Patient is a Muslim and practices his religion.
f. Social Activity History
Prior to the onset of the complaint, he was known to be sociable person.
g. Millitary History
There is no military history.
h. Legal History
Patient never associated with any legal problems.
i. Current Living Situation
Patient currently lives with his Uncle. Their residency is a 10 x 8 meter
house. Lighting and ventilation are adequate.

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Fakultas Kedokteran Universitas Tanjungpura
E. Family History
There was patients family members suffers from the same complaint or
any other psychiatric symptoms which is his grandfather.

Genogram :

: Male : Female
: Passed away
: Patient : Live in one house

E. Progression of Disorder

Symptoms

4 months 1 months 1 weeks


ago ago ago

Role of Function

III. PHYSICAL EXAMINATION

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Fakultas Kedokteran Universitas Tanjungpura
A. Reviews of Systems
Examination was conducted on 10th of April 2017 in the patients previously-
mentioned residency.

1. Consciousness : Compos Mentis


2. Vital Sign
Blood Pressure : 110/70 mmHg
Heart Rate : 88x/minute
Respiratory Rate : 18x/minute
Temperature : 36,5 C
3. Head ( Eye, Ear, Nose and Throat )
Head : Normocephal
Eye : Conjunctiva anemic -/-, sclera icteric -/-
Ear : Normotia/normotia, secret -/-
Nose : Cavum nasi clear/clear, secret -/-
Throat : Pharynx hyperemic (-)
4. Thorax
a. Cardiovascular System
Inspection : Ictus cordis visible
Palpation : Ictus cordis palpate on ICS 5-6
Auscultation : Regular Heart sounds,
murmur (-), gallop (-)
b. Respiratory System
Inspection : Chest wall expansions : symmetric
Palpation : Vocal fremitus right=left
Percussion : Sonor right=left
Auscultation : Breath sound: vesicular

5. Gastrointestinal System
Inspection : flat
Auscultation : bowel sounds (+) normal

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Fakultas Kedokteran Universitas Tanjungpura
Palpation : Soepel, tenderness (-)
Percussion : Tymphani
6. Urogenital System : has not been performed
7. Menstrual history : There are no abnormality findings in
menstrual history
8. Extremity :
Superior Inferior
Oedem -/- -/-
Cyanosis -/- -/-
Temperature warm/ warm warm/warm
Capillary refill test <2sec <2sec
Deformity -/- -/-

B. Neurological Examination
Examination has been performed on January, 23rd, at patient house.
1. Meningeal Sign :
- Nuchal Rigidity : (-)
- Laseque : (-)
- Kernique : (-)
- Brudzinski I, II : (-)
2. Cranial Nerve I - XII : normal
3. Motor System :
Motor Superior Inferior
Movement N/N N/N
Strength 5/5 5/5
Tone N/N N/N
Trophy E/E E/E

4. Sensory System : normal


5. Physiological Reflex : ++/++
6. Pathological Reflex : - /-

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Fakultas Kedokteran Universitas Tanjungpura
C. Mental Status Examination
Examination was conducted on 10th of April 2017 in the patients previously-
mentioned residency.
A. General Description
1. Appearance
A male, appropriate with patients age, good personal hygiene
2. Psychomotor Activity and Attitude toward Examiner
Cooperative, normoactive. Patient frequently lower his head,
because he seems to be shy.
3. Speech Characteristics
Normally responsive to cues from the interviewer but slow and
emotional.
Quality : Normal
Quantity : Normal
4. Consciousness
a. Neurologic : Compos Mentis
b. Psychologic : Clear
5. Conversation
The patient is not talkactive, his speech is loud and clear.

B. Mood and Affect


1. Mood : Depressed, stabile
2. Affect : Constricted (the range and intensity of
expression are reduced), appropriate

C. Perception
1. Illusions : (-)
2. Hallucinations : (-)
3. Depersonalization : (-)
4. Derealization : (-)
D. Thought Process
1. Thought Progression

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a. Quantity : Remming
b. Quality : Coherent
2. Thought content : Delusion (-), pessimism
3. Form of Thinking : Realistic
E. Sensorium and Cognition
1. Consciousness : Clear
2. Orientation
Time : Fine
Place : Fine
Person : Fine
Situation : Fine
3. Memory
Remote memory : no impairment
Recent past memory : no impairment
Recent memory : no impairment
Immediate retention and recall : no impairment
4. Concentration and Attention : The patient is easily distracted
5. Reading and Writing : Fine
6. Visuospatial ability : Fine
7. Abstract Thought : Fine
8. Information and Intelligence : Fine
F. Impulsivity
Self control during examination : Enough
Patient response toward examiner : Enough

G. Judgement and Insight


- Judgement : Patient understand the likely outcome of her
behavior
- Insight : True insight ()

IV. RESUME

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Fakultas Kedokteran Universitas Tanjungpura
The patient has been feeling morose since 4 months ago, this
complaint is accompanied with loss of appetite and difficulty in sleeping.
The patient stated that she has been feeling fatigued lately. The symptoms
has been getting worse in the last month during which her frequency of
interaction with her family and her neighbors has been decreasing. She has
locking herself in her room more often. She stated that she has resigned to
her problems and has been spending most of her time praying.
From our psychiatric examination on 23rd of January 2017, we
found that her quantity of speech is declining, she has been acting
hypoactively, her mood has been sad with a restricted affect. Her stream of
thought was remming quantitatively and coherent qualitatively. Its
contents were disappointment, resignation and pessimism.

V. Diagnostic Formulation
Symptoms:
- Decreased of Activities
- Lack of Conversation
- Apathy
- Hypoactive
- Sad Mood
- Restricted Affect
- Remming
- Contents of thought: disappointment, resignation and pessimism

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Fakultas Kedokteran Universitas Tanjungpura
Depression Syndrome : Depression affect, loss of interest and excitement,
reduced energy, feeling fatigue, idea of
disappointment, idea of resignation, pessimism,
difficulty in sleeping, lack of appetite

VI. DIFFERENTAL DIAGNOSES


According to Diagnosis Gangguan Jiwa PPDGJ-III :
a. Severe Depressive Episode without Psychotic Symptoms (F32.2. Episode
Depresif Berat tanpa Gejala Psikotik)
b. Recurrent Depressive Disorder, current Severe Episode without Psychotic
Symptoms (F33.2. Gangguan Depresif Berulang, Episode Kini Berat tanpa
Gejala Psikotik)
c. Bipolar Disorder, current Severe Depressive Episode without Psychotic
Symptoms (F31.4. Gangguan Afektif Bipolar, Episode Kini Depresif Berat
tanpa Gejala Psikotik)

VII. DIAGNOSIS
F32.- Episode Depresif (Depressive Episode)
Gejala Utama Fulfilled
a. Afek depresif
b. Kehilangan minat dan kegembiraan
c. Berkurangnya energi yang berujung meningkatnya
keadaan mudah lelah dan menurunnya aktivitas
Gejala Lainnya Fulfilled
a. Konsentrasi dan Perhatian kurang
b. Harga diri dan kepercayaan diri kurang
c. Gagasan tentang rasa bersalah dan tidak berguna
d. Pandangan masa depan yang suram dan pesimistis
e. Gagasan atau perbuatan membahayakan diri atau bunuh diri
f. Tidur terganggu

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g. Nafsu makan berkurang
Diperlukan masa sekurang-kurangnya 2 minggu untuk penegakan Fulfilled
diagnosis, akan tetapi periode lebih pendek dapat dibenarkan jika
gejala luar biasa beratnya dan berlangsung cepat

F32.2 Episode Depresif Berat tanpa Gejala Psikotik (Severe Depressive Episode
without Psychotic Symptoms)
Semua 3 gejala utama depresi harus ada Fulfilled
Ditambah sekurang-kurangya 4 dari gejala lainnya, dan beberapa Fulfilled
diantaranya harus berintensitas berat
Bila ada gejala penting (misalnya agitasi atau retardasi psikomotor) Fulfilled
yang mencolok, maka pasien mungkin tidak mau atau tidak mampu
untuk melaporkan banyak gejalanya secara rinci
Episode depresif biasanya harus berlangsung sekurang-kurangnya 2 Fulfilled
minggu, akan tetapi jika gejala amat berat dan beronset sangat
cepat, maka masih dibenarkan untuk menegakkan diagnosis dalam
kurun waktu kurang dari 2 minggu
Sangat tidak mungkin pasien akan mampu meneruskan kegiatan Fulfilled
social, pekerjaan, atau urusan rumah tangga, kecuali pada taraf
yang sangat terbatas.

F33.2 Gangguan Depresif Berulang, Episode Kini Berat tanpa Gejala Psikotik
(Recurrent Depressive Disorder, current Severe Episode without Psychotic Symptoms)
Kriteria untuk gangguan depresif berulang harus dipenuhi, dan Fullfilled
episode sekarang harus memenuhi kriteria untuk depresif berat
tanpa gejala psikotik
Sekurang-kurangnya dua episode telah berlangsung masing-masing Un-Fullfilled
selama minimal 2 minggu dengan sela waktu beberapa bulan tanpa
gangguan afektif yang bermakna

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Fakultas Kedokteran Universitas Tanjungpura
F31.4 Gangguan Afektif Bipolar, Episode Kini Depresif Berat tanpa Gejala Psikotik
(Bipolar Disorder, current Severe Depressive Episode without Psychotic Symptoms)
Episode yang sekarang harus memenuhi kriteria untuk episode Fullfilled
depresif berat tanpa gejala psikotik
Harus ada sekurang-kurangnya satu episode afektif hipomanik, Un-Fullfilled
manik, atau campuran di masa lampau

VIII. MULTIAXIAL EVALUATION


AXIS I : F32.2. Severe Depressive Episode without Psychotic
Symptoms
AXIS II : Introvert
AXIS III : Not yet diagnose
AXIS IV : Heavy workload
AXIS V : GAF 50-41 Serious symptoms, Severe disability

IX. PROBLEM LIST


Problems Description
Organobiology Decrease in the activity of one or more
neurotransmitters (serotonin, norepinephrine,
dopamine)
Psychopathology Quantity of speech is declining, sad mood, restricted
affect, anxiety
Social Limitations in social interaction and role function

X. PROGNOSIS
PREMORBID
History of mental illness in the family (+) : Poor
Marital status (Not yet married) : Poor
Family support (Good) : Good
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Fakultas Kedokteran Universitas Tanjungpura
Socio-economic status (Low) : Poor
Stressors (Quite clear) : Good

MORBID
Onset age (22 yo) : Poor
Response to therapy (Good) : Good
Medication adherence (not yet known) :-

Ad vitam : Bonam
Ad functionam : Dubia ad bonam
Ad sanactionam : Dubia ad bonam

XI. Therapy Planning


A. Psychopharmacology
- Nopres 1x0,5 20 mg (taken in the morning)
- Haloperidol 2x 10 mg
- Clobazam 1x1 10 mg (taken in the night)

B. Psychotherapy
- Supportive Psychotherapy
- Family Psychoeducation

XII. DISCUSSION
A. Psychopharmacology
Depressive syndrome is caused by relative deficiency of one or more
aminergic neurotransmitters like norepinephrine, serotonin or dopamine in
synapses of central nervous system especially in the limbic system which
decreases the activity of serotonin receptor. Antidepressants work by
inhibiting aminergic neurotransmitters uptake in this area and slowing the
breakdown of monoamine oxidase. This causes an increasing number of

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Fakultas Kedokteran Universitas Tanjungpura
aminergic neurotransmitters in the synapses which in turn increases the
activity of serotonin receptors.
Antidepressant is the drug of choice for this patient, to which we
prescribed fluoxetine. Fluoxetine is the most widely used selective
serotonin reuptake inhibitor (SSRI) as it causes minimal anticholinergic,
sedation and cardiological side effects and is sufficient even when given in
a single dose. Her fluoxetine regime is 20 mg every 24 hours, taken in the
morning.
This patient has been feeling uncomfortable sleeping and frequently wakes
up from her night sleep since more or less 4 months. The trouble sleeping
in the case of depression, there is a reduction of delta sleep that makes
patients cannot sleep deeply and easily awakened. The drug of choice for
this condition is a mid-long acting sedative agent which supress and
eliminate REM sleep and improve delta sleep to which we prescribed
Clobazam 10 mg every 24 hours, taken in the night.

B. Non-Pharmacotherapy
Supportive Psychotherapy
We motivated and gave her emotional support so that she could
function well again, both physically and socially. We also encouraged
her to take her medication as prescribed. Supportive psychotherapy
was given to strengthen her mental strength, develop a better coping
mechanism and restore her adaptive balance. Supportive
psychotherapy will be started when she has calmed down and when her
knowledge of her condition has improved.
Family Psychoeducation
We also asked her family members to play active roles in every step of
her recovery. We explained to them how important her medication is
towards her recovery in hopes that they would help monitoring her
obedience in taking her medication. They need to know the side effects

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Fakultas Kedokteran Universitas Tanjungpura
of her medication as well. We also motivated them to collectively help
her by spending more time with her by approaching her so that she will
open up to them.

GALLERY

Driveway
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Driveway

Left Side View

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Right Side View

Front Side View

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Backyard View

Backyard View

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Living Room

Note : We were not allowed to take pictures inside the patients house.

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Fakultas Kedokteran Universitas Tanjungpura