I.

PERSONAL IDENTITY

Name : Mrs. Y
Age : 55 years old
Sex : Female
Adress : Tempuran
Ethnic : Javanese
Religion : Moslem
Prior Education : Elementary School
Occupation : Labor
Marital state : Widow

II. PSYCHIATRY HISTORY

History was obtained from alloanamnesis December 7th 2015 in psychiatric’s poli.

Identity I

Name Mrs. W

Age 35 years old

Sex Female

Address Tempuran

Ethnic Javanese

Religion Moslem

Occupation Housewife

Marital State Married

Relation with Patient Daughter

Case Based Discussion Non Psychotic Case 1

Fakultas Kedokteran Universitas Tanjungpura
A. The Reason Brought Patient to Hospital
The patient was brought to RSJS Magelang by her family on December 7th, 2015
because she often felt her heart pounding and felt dizzy.

B. Progression of illness
Five years ago (In 2010), the patient has changed behavior after seeing her husband
was fighting with her brother. Her husband was very angry with her brother and wanted
to kill him. He fought with a big knive in his hand. The patient was very frightened of
this and she felt shock. She got a chestpain and she felt dizzy. Her heart couldn’t stop
beating so quickly and she couldn’t be able to sleep.
The scene was played in her mind repeatedly and she couldn’t erase that memories
from her mind. Everytime she remembered that scene, her heart began to beat so fast
and she got a chestpain. She more often felt dizzy so she just lay in bed and had no
desire to eat. She couldn’t think clearly and hard to concentrate. She quited from her
job and just took care of her house.
The patient couldn’t be able to see a fight anymore. Everytime she saw a fight, she
began to imagine the same situation like one that happened before between her husband
and her brother. Everytime she heard news about the death, she also felt the same. And
if her children didn’t tell her about their condition, she often felt worried.
The patient felt that there’s something wrong with her and she began to treat herself
with traditional treatment in 2011. After 4 years, she felt that there’s no change and she
had no hope. She went to the hospital and had ECG and thorax rontgen but the doctors
said that she was just fine. In 2014 her husband was dead, and she felt worse than
before. She couldn’t sleep well, have no appetite to eat and felt sad and desperate
because of his death.
In 2015, one of her family suggested her to go to RSJS Magelang and she visited
the psychiatric policlinic routinely. She felt better and she started to work as a labor
again until now.

Case Based Discussion Non Psychotic Case 2

Fakultas Kedokteran Universitas Tanjungpura
C. History of past illness
1. Psychiatric History
There’s no history about psychiatric illness before.
2. General Medical History
There was no history of high fever, seizure, head trauma, any other systemic disease
or any other serious illness which needs hospitalization.
3. Drugs, Alcohol and Smoking history
The patient has no history of subtance abuse like drugs, alcohol, and smoke.

D. History of Personal Life

1. Prenatal and Perinatal
 The patient was fourth child from eight siblings. Her mother age was 36
years old when she was pregnant plained and wanted and her condition was
well. The delivery was assisted by traditional birth helper after 38th weeks
of pregnancy. She was spontanity and normality of delivery. She wasn’t
being immunization.
 There was no valid data about the condition of patient when he was was
born such as activity arm and leg flexed (motoric tone), active movement,
heart rate, grimace (reflex irritability), appearance (skin colour), and
respiratory rate respiration (APGAR score)
2. Early Childhood (0-3 years old)
 There was no valid data about feeding habits of patient, is it breast feed or
bottle feed, and was she having any eating problem.
 There was no valid data about symptoms or behavior problems such as tumb
sucking, temper tantrum, tics, head bumping, rooking night terrors, fears,
bed wetting or bed soiling and nail bitting.

Case Based Discussion Non Psychotic Case 3

Fakultas Kedokteran Universitas Tanjungpura
  There was no valid data about patient’s early childhood history such as the
first time patient lifting the head and body, supine the prone, sitting,
standing, walking, smiling, holding her own hand, scoop up the object,
holding pencil and pilling up two objects.
 There was no valid data about the first time patient replying to smile,
smiling when seeing interesting object, playing “cilukba”, knowing his
family members and pointing what she wanted without crying.
 There was no valid data about the first time patient bubbling, cooing,
making sounds without meaning, telling 2-3 syllables without meaning and
calling “mama/papa”.
 There was no valid data about the first time patient copying sounds that she
heard for the first time and understanding simple orders.
 There was no valid data about the first time patient playing, frightened by
strangers, starting to show jealousy or competitiveness towards other and
toilet training.
3. Middle Childhood Phase (3-11 years old)
 There was no valid data about the first time patient climbing on tree or play
hide and seek games and if patient ever involved in any kind of sports.
 There was no valid data about the first time patient gender identification,
interaction with his surrounding.
 She was entered elementary school when she was 7 years old. But she didn’t
passed the elementary school.
 There was no valid data about patient’s ability to make friends in school
and how many friends patient have during hes schooling period.
 There was no valid data about patient adaption under stress.
 The patient’s grades in school was good and has ordinary achievement at
school.
4. Late Childhood Phase (11-18 years old)

Case Based Discussion Non Psychotic Case 4

Fakultas Kedokteran Universitas Tanjungpura
  There was no valid data about patient school history, her achievement,
relationship with teachers or favourite studies. There was also no valid data
about patient’s participation in sport and hobbies, her attitude at school,
how many her friends, social popularity or participation in group activities,
 There was no valid data about patient’s relationship with opposite gender.
 There was no valid data about her emotional and physical problem,
nightmare, phobias, bed-wetting and how the patient solve her problem.
 The patient’s relationship between patient and parents and other family is
lack of communication. She prefered to be alone in her room.
5. Adulthood Phase (18 years old -now)
a) Educational History
 The patient entered elementary school when she was six years old. She
didn’t passed from elementary school
 There was no valid data about patient school history, her achievement,
relationship with teachers or favourite studies. There was also no valid
data about patient’s participation in sport and hobby, his attitude at
school, how many her friends, social popularity and participation in
group activities.
b) Occupational History
After she didn’t passed elementary school, she just stay at home to help
her mother. And then she married with her husband so she followed her
husband to be trader. After her husband was dead, she worked as a labor
until now.
c) Spiritual History
She is a moslem. She believes her God. But since she was ill, she rarely
prays on five times.
d) Law and Criminal History

Case Based Discussion Non Psychotic Case 5

Fakultas Kedokteran Universitas Tanjungpura
 Patient has no history of criminal data and never been involved with
police.
e) Social Activity
Normal interaction with his family, friends, and neighbors before and
after sick. Patient tried to keep secretly her illness. Patient tend to keep her
problems alone.

f) Marital and Relationship History

Patient married with her husband when she was 17 years old. She
married with him because she like him and then she decided to agree
married with him.
Her husband was a tempered person. He often felt angry to her as
they went home after work. Most of them were because they felt tired, so
her husband often felt angry because of little things.
She usually keep her problems alone and didn’t tell her husband what
her feeling actually. Even about her illness, she didn’t tell her husband too.

E. Family History
There was no psychiatric history in patient’s family.
Genogram:

Case Based Discussion Non Psychotic Case 6

Fakultas Kedokteran Universitas Tanjungpura
Explanation :
= Male
= Female
= Patient
= Live together in same house
= Death (Male)

= Death (Female)

F. Present Life Situation

Nowadays, the patient lives alone in her house. She had a small house with a small
yard. The house consist of a living room, a dining room, one bedroom, a kitchen, a
warehouse and the bathroom out of the house. The patient’s income was got from her
salary as a labor. Usually, her children also give her money. She went work at 8 o’clok
and went home at 16.00.

G. Psychosexual History
The patient’s is appropriate to his gender. The patient realizes that she is female and
she acts like female. She prefers to play with peers female friends.There was also no
valid data about the first time she attracted to male.

III. MENTAL STATE (December 7th 2015)

A. Appearance
A female that appropriate to her age, weared completely clothes and had good self care
B. State of Consciousness
Clear
C. Connection of psychic
 Attention easily attracted, sustained concentration(+)

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Fakultas Kedokteran Universitas Tanjungpura
  Attention easily attracted, unable to sustained concentration
 Difficult to attracted, unable to sustained concentration
D. Behaviour
 Normoactive (+)  Aggressive  Somnabulism
 Hypoactive  Mannerism  Psychomotor
 Hyperactive  Automatism agitation
 Echopraxia  Command  Compulsive
 Catatonic automatism  Ataxia
 Active negativism  Impulsive  Mimicri
 Cataplexy  Acathysia  Abulia

E. Attitude
 Cooperative(+)  Distrust
 Non-cooperative  Labile
 Indifferent  Rigid
 Apathy  Passive negativism
 Tension  Stereotiphy
 Dependent  Catalepsy
 Passive  Cerea flexibility
 Infantile  Excitement

F. Speech
1. Quantity
 Increase
 Normal(+)
 Decrease
2. Quality
 Normal(+)

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Fakultas Kedokteran Universitas Tanjungpura
  Decrease
G. Mood and Affect
1. Mood
 Dysphoric  Expansive
 Euthimic(+)  Irritable
 Elevated  Agitation
 Euphoria
2. Affect
 Appropiate(+)  Flat
 Inappropiate  Labil
 Restrictive  Stable(+)
 Blunted
H. Perception
1. Disurbance of perception
 Auditory  Tactile
 Visual  Gustatory
 Olfactory
2. Illution
 Auditory  Tactile
 Visual  Gustatory
 Olfactory
3. Depersonalization : There was no depersonalization
4. Derealization : There was no derealization
I. Thought
1. Progression of thought
a)Quality:
 Irrelevant answer  Coherence(+)
 Incoherence  Flight of idea

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Fakultas Kedokteran Universitas Tanjungpura
  Confabulation  Circumstansial
 Neologisme  Tangensial
 Verbigation  Word Salad
 Preservation  Echolalia
 Loosening of association
b) Quantity :
 Talk active  Remming
 Logorrhea  Mutism
 Blocking  Normal (+)

2. Content of thought
 Idea of reference  Delution of control
 Idea of guilt  Delution of passivity
 Preoccupation  Delution of persecution
 Obsession  Delution of reference
 Phobia  Delution of envious
 Thought echo  Delution of hypocondric
 Thought withdrawal  Delution of grandious
 Thought insertion  Delution of influence
 Thought broadcasting
3. Form of thought
 Realistic(+)
 Unrealistic
 Dereistic
 Autistic
J. Insight
 Impaired insight

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Fakultas Kedokteran Universitas Tanjungpura
  Intellectual insight
 True insight (+)
K. Sensorium and Cognition
1. Orientation :
 Time : Good
 Place : Good
 Person : Good
 Situation : Good
2. Level of Education : Less
3. General knowledge : Less
4. Long Memory : Less
5. Short memory : Moderate
6. Concentration : lack
7. Writing and reading skills : Moderate
8. Ability to be independent : Good

IV. INTERNAL STATE

A. State of Conciousness : Compos Mentis
B. Vital sign
1. Blood pressure : 120/70 mmHg
2. Pulse rate : 84 times/minutes
3. Respiration rate : 20 times/minutes
4. Temperature : 36,50C
C. Head
1. Head : Normocephali (+)
2. Eye : Anemic conjungtiva (-/-), icteric sclera (-/-)
3. Nose : Discharge (-), septum deviation (-)
4. Ear : Discharge (-/-)

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Fakultas Kedokteran Universitas Tanjungpura
 5. Mouth : Faring hyperemis (-), enlargement of tonsil (-)
6. Neck : Trachea deviation (-), enlargement of lymph node (-)
D. Thorax :
1. Cor
 Inspection : Ictus cordis can’t be seen
 Palpation : Ictus cordiscan be feltat ICS 5-6
 Auscultation : S I/II regular heartsound, murmur (-), gallop (-)
2. Pulmo
 Inspection : Simetric in static and dynamic condition
 Palpation : Fremitus tactil right and left similar
 Percution : Sonor in right and left lungs
 Auscultion : Vesicular breath sounds (+/+), ronchi (-/-), wheezing (-
/-)
E. Abdomen :
 Inspectioni : Stomach look flat, mass (-), scar (-)
 Auscultation : Bowel sound (+) normal
 Palpation : Tenderness (-), mass (-), hepar and lien unpalpable
 Percucion : Tympanic in all quadrant
F. Extremity :
Superior Inferior
Oedem -/- -/-

Sianosis -/- -/-

Akral warm/ warm warm/warm

Cappilary refill test <2second <2 second

Deformity -/- -/-

G. Neurological State

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Fakultas Kedokteran Universitas Tanjungpura
1. GCS : E4M6V5
2. Head : Normocephali (+), symmetric (+), pain (-),
deformity (-)
3. Neck : Trachea deviation (-), enlargement of lymph
node (-)
4. Vertebrate : Deformity (-),pain (-)
5. Meningeal sign : Not assessed
6. Sensoric : Not assessed
7. Motoric :
Motoric Superior Inferior

Movement N/N N/N

Strength 5/5 5/5

Tone N/N N/N

Trofi E/E E/E

8. Cranial Nerve
Examination Dextra Sinistra

N I (Olfactory) Good Good

N II (Opticus) Good Good

N III (Occulomotorius)
- Ptosis - -
- Size of pupil 3 mm 3 mm
- Form of pupil Round Round
- Direct light reflex + +
- Indirect light reflex + +
- Divergen strabismus - -

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Fakultas Kedokteran Universitas Tanjungpura
 - Eye’s movement to medial + +
- eye’s movement to superior + +
- Eye’s movement to inferior. + +
N IV (Trochlear)
- Eye’s movement to lateral + +
inferior
N V (Abducens)
- Eye’s movement to lateral + +

N VI (Trigeminus)
- Bite Good Good
- Open the mouth Good Good
- Sencibillity of face Good Good
- Corneal reflex + +
- Trismus - -
N VII (Facialis)
- Wink of eyes Good Good
- Fold of naso-labial Good Good
- Angle of mouth Symmetric Symmetric
- Symmetric face + +
- Gustatory of 2/3 tongue Not assessed Not assessed

N VIII (Vestibulocochlearis) Good Good

N IX (Glosofaringeus)
- Arcus of pharyng Normal Normal
- Gustatory of 1/3 posterior of Not assessed Not assessed
tongue + +
- Uvula in the middle - -
- Talk through the nose

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Fakultas Kedokteran Universitas Tanjungpura
 N X (Vagus)

- Swallowing
N XI (Assecorius)

- Swing round the neck Good Good

- Up the shoulder Good Good
- Trofi Eutrofi Eutrofi
N XII (Hypoglossus)
Good Good
- Articulation
Good Good
- Out the tongue
- -
- Tremor
Eutrofi Eutrofi
- Trofi
Good Good
- Fasciculation

9. Physiologic and pathological reflex :

Physiologic reflex
- Biceps ++ ++
- Triceps ++ ++
- Patella ++ ++
- Achilles ++ ++
Pathological reflex
- Hoffman-tromner - -
- Babinski - -
- Oppenheim - -
- Gonda - -
- Schaeffner - -
- Gordon - -
- Chaddock - -

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Fakultas Kedokteran Universitas Tanjungpura
 10. Otonom and Coordination :
Otonom
- Defecation Good
- Miction Good
- Salivation Good
- Perspiration Good
Coordination
- States Not assessed
- Sit Not assessed
- Stand Not assessed
- Romberg test Not assessed
- Fast pointing Not assessed
- Finger to nose Not assessed
- Fnger to finger Not assessed
- Disdiadokinesis Not assessed
- Knee to heel Not assessed
- Tandem walking Not assessed

V. RESUME
A female, 55 years old, came to the RSJS Magelang because she often felt chestpain
and felt dizzy. Five years ago (In 2010), the patient has changed behavior after seeing
her husband was fighting with her brother. Her husband was very angry with her
brother and wanted to kill him. He fought with a big knive in his hand. The patient was
very frightened of this and she felt shock. She got a chestpain and she felt dizzy. Her
heart couldn’t stop beating so quickly and she couldn’t be able to sleep.
The scene was played in her mind repeatedly and she couldn’t erase that memories
from her mind. Everytime she remembered that scene, her heart began to beat so fast
and she got a chestpain. She more often felt dizzy so she just lay in bed and had no

Case Based Discussion Non Psychotic Case 16

Fakultas Kedokteran Universitas Tanjungpura
desire to eat. She couldn’t think clearly and hard to cocentrate. She quited from her job
and just took care of her house.
The patient couldn’t be able to see a fight anymore. Everytime she saw a fight, she
began to imagine the same situation like one that happened before between her husband
and her brother. Everytime she heard news about the death, she also felt the same. And
if her children didn’t tell her about their condition, she often felt worried.
The patient felt that there’s something wrong with her and she began to treat herself
to traditional treatment in 2011. After 4 years, she felt that there’s no change and she
had no hope. She went to the hospital and had ECG and thorax rontgen but the doctors
said that she was just fine. In 2014 her husband was dead, and she felt worse than
before.In 2015, one of her family suggested her to go to RSJS Magelang and she took
control of herself routinely. She felt better and she started to work as a labor again until
now.
Patient married with her husband when she was 17 years old. She married with him
because she like him and then she decided to agree married with him. Her husband was
a tempered person. He often felt angry to her as they went home after work. Most of
them were because they felt tired, so her husband often felt angry because of little
things.
She usually keep her problems alone and didn’t tell her husband what her feeling
actually. Even about her illness, she didn’t tell her husband too.

VI. SYNDROME FINDINGS

 Reduce energy, lackness

Syndrome of depression
 Sleep disturbance
 Decrease in appetite
 Diminished to think or
concentrate

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Fakultas Kedokteran Universitas Tanjungpura
  Worried
Syndrome of anxiety
 Dizzy
 Autonomic overactivity

VIII. MULTIAXIAL DIAGNOSTIC

AXIS I : F41.2 Mixed Anxiety and Depression
AXIS II : Z03.2 there is no diagnosis of axis II

AXIS III : There is no diagnosis of axis III

AXIS IV : Problem with primary support group

AXIS V : GAF admission 70-61

IX. PROBLEM RELATED TO PATIENT

Problem Description
Organobiology There were abnormality imbalance
neurotransmitter, serotonin, dopamine and
norepinephrine.
Psychology The patient had poor appetite and couldn’t
sleep well
The patient often felt worried
Social The patient was a closed person before he
sick.
The patient never told any of his problems to
his family or friends
The patient rarely communicated with her
family.

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Fakultas Kedokteran Universitas Tanjungpura
X. THERAPY MANAGEMENT PLANNING
1. Hospitalization
No indication
2. Respons Phase
The target of therapy was 50% decrease symptoms
a. Antidepressant
Fluoxetine 1 x 20 mg
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
b. Antiaxiety
Clobazam 1 x 5 mg
Benzodiazepine as anti-anxiety have a high therapeutic ratio, less addiction with
low toxicity. Clobazam as a psychomotor performance.

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 to her family about her problem and her mental
disorder and how to treat it. Its important for the family to be support, compfort,
and don’t avoid her. Provide guidanceto the familyto keepactive role
ineverypatient management process. Briefed the families about the importance
ofthe drug tot he patient's recovery so families need to remind and monitor the
patient to take medication irregularly. Effect drug side also told the family. To

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Fakultas Kedokteran Universitas Tanjungpura
 motivate families to get together to help patients recover with respect to the
patient as an individual.
 Helping patients to use other abilities. Motivate and provide support so that the
patient's physical and social functioning optimally and motivate patients to take
the drug regularly.

XII. PROGNOSIS
Premorbid
 History of disease in the family : good
 Marital status : bad
 Family support : good
 Socio-economic status : good
 Stressor : good
 Premorbid personality`` : bad

Morbid

 Type of disease : good

 Course : bad
 Organic disease : good
 Treatment response : good
 Adherence to take medication : good

Prognosis
Ad Vitam : Bonam
Ad Fungctionam : Bonam
Ad Sanactionam : Bonam

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Fakultas Kedokteran Universitas Tanjungpura
 REFERENCES

1. Kaplan dan Sadock. Sinopsis Psikiatri jilid 2, Ilmu Pengetahuan Perilaku dan
Psikiatri Klinis. Edisi Ketujuh.Jakarta : Binarupa Aksara.2010.

2. Maslim R. Panduan Praktis, Penggunaan Klinis Obat Psikotropik. Cetakan III.

PT Nuh Jaya. Jakarta.2007. h : 23-30

3. Maslim R. Diagnosis Gangguan Jiwa, Rujukan Ringkas PPDGJ-III. Bagian

Ilmu Kedokteran Jiwa FK UNIKA Atma Jaya. Jakarta.2003.

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LAMPIRAN FOTO HOME VISIT (9th December 2015)

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Fakultas Kedokteran Universitas Tanjungpura
 Case Based Discussion Non Psychotic Case 23
Fakultas Kedokteran Universitas Tanjungpura