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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
Name : Mr. P
Sex : Male
Age : 44 yo
Address : Danurrejo
Ethnic : Javanese
Religion : Islam
Occupation : Labour
Marital State : Married
Relation : Uncle
A. Chief Complaint
The patient has been feeling morose since ± 4 months ago.
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.
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 wasn’t 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.
Genogram :
: Male : Female
: Passed away
: Patient : Live in one house
E. Progression of Disorder
Symptoms
5. Gastrointestinal System
Inspection : flat
Auscultation : bowel sounds (+) normal
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
C. Perception
Case Based Discussion Non-Psikotik 8
Fakultas Kedokteran Universitas Tanjungpura
1. Illusions : (-)
2. Hallucinations : (-)
3. Depersonalization : (-)
4. Derealization : (-)
D. Thought Process
1. Thought Progression
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
IV. RESUME
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
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
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
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
X. PROGNOSIS
Case Based Discussion Non-Psikotik 13
Fakultas Kedokteran Universitas Tanjungpura
PREMORBID
History of mental illness in the family (+) : Poor
Marital status (Not yet married) : Poor
Family support (Good) : Good
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
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
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
GALLERY
Driveway
Backyard View
Living Room
Note : We were not allowed to take pictures inside the patient’s house.