LAPORAN KEGIATAN PUSKESMAS

DUAL DIAGNOSIS

Pembimbing:
dr. Sabar Paluhutan Siregar, Sp. KJ

Arif Padillah I 1011131045

Herwandi I 1011141003
Fithriyyah I 1011151001
Ummul Hayati I 1011151006
Ade Elsa Sumitro Putri I 10111510651

KEPANITERAAN KLINIK ILMU KESEHATAN JIWA

RSJ PROF. DR. SOEROJO MAGELANG

PERIODE 15 JULI – 16 AGUSTUS 2019

FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNGPURA

PONTIANAK

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I. PATIENT PERSONAL IDENTITY

Name : Ny. M
Birth date : 4 April 1979
Age : 40 tahun
Jenis kelamin : Wanita
Pekerjaan : Berjualan
Agama : Islam
Suku bangsa : Jawa
Status perkawinan : Menikah
Alamat : Dusun Sutan, Sumberejo

II. PYSCHIATRIC HISTORY

Obtained from autoanamnesis 7 July 2019

III. MAIN COMPLAINT

Patients come to the Puskesmas Metroyudan I for treatment with complaints of
dizziness & nausea.

IV. HISTORY OF DISEASE DEVELOPMENT

The patient comes to the puskesmas to complain that her head feels dizzy and has
nausea and continues to burp, besides that the patient feels the nape of his neck felt tense
since a week ago and his right hand feels aching and tingling, as well as aches. The
patient says if his mind becomes tense, he will be lazy to eat. The patient said that he had
a history of gastritic before.
When asked why the patient could feel tense, the patient said that she was
depressed by the nature of her parents in-laws at home which made her think
continuously. The father in-laws of the patient suffer from lung disease until they are
hospitalized but are still stubborn to smoke, and the mother in-laws often talk to gossip
about others and their families, so these two things make the patient feel uncomfortable at
home.
Patients have complained since they stopped working as laborers at the Aloe Vera
factory in 2010 and spent time at home, patients began to feel sad and have trouble
sleeping, sometimes when she fall asleep they will wake up and cannot sleep anymore.

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 The patient said that the patient's feelings were agitated because of both patients' parents-
in-law behaviour, especially the character of her mother’s in-laws who made the patient
avoid him if she had returned home from the fields so as not to hear the gossip being said.
Patients will choose to sit in front of the house by playing mobile phones, going around
the house, or going to work.
The patient feels her appetite begins to decrease lately and is easily tired. The
patient had asked to separate the house from the in-laws of the husband, but the husband
couldn’t comply it because the patient's husband was the youngest child that have
responsibility to take care his parents. The patient said that she could only continue to be
patient and pray, and was strengthened by her father and mother in order to stay
motivated in living with her parents-in-law and consider it a test of life. Since 2017 the
patient began to have high blood pressure until now, the patient previously claimed that
she have no history of high blood pressure or other metabolic diseases.

V. PAST ILLNESS HISTORY

1. Psychiatric
-
2. General medical history
History of head trauma (fall), history of seizures (-), history of high fever (-).
History of DM (-), History of high blood pressure (+)
3. Alcohol or durgs
There is no history of alcohol use, drugs and other substances
VI. RIWAYAT KEHIDUPAN PRIBADI
1. Riwayat Prenatal dan Perinatal
Ibu dalam keadaan sehat sewaktu mengandung pasien. Pasien dilahirkan di rumah,
secara spontan, cukup bulan, ditolong dukun.. Pasien adalah anak kedua dari 5
bersaudara. Sejak kecil, pasien tinggal bersama kedua orang tua. Selama itu tidak ada
riwayat kejang, trauma kepala dan panas tinggi.
2. Riwayat Masa Kanak Awal (usia 0-3 tahun)`
Riwayat tumbuh kembang dalam batas normal. Pasien diasuh oleh kedua orang tua.
Ayah pasien bekerja sebagai buruh dengan kondisi sosial ekonomi yang pas-pasan.
3. Riwayat Masa Kanak Pertengahan (usia 3-11 tahun)
Pada masa ini pasien tumbuh dan berkembang seperti anak-anak seusianya. Pasien
termasuk anak yang cukup aktif, dapat bergaul dan bermain dengan teman-teman

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 perempuan sebayanya, tidak ada kesulitan bermain bersama anak-anak lain di
kampungnya. Pada saat ini pasien bisa menerima apabila ada keinginannya yang tidak
terpenuhi dan cenderung mengalah. Tidak didapatkan adanya persaingan dengan
saudara-saudara yang lain. Pasien diajarkan sholat, mengaji dan pemahaman nilai
agama oleh ibu pasien. Pasien tidak pernah tinggal kelas. Pada saat setelah lulus SD,
pasien mulai bekerja ikut membantu ayah.
4. Riwayat Masa Kanak Akhir dan Remaja
Pasien mulai merantau untuk bekerja sebagai buruh lepas di Kalimantan.
5. Riwayat Masa Dewasa
a. Riwayat Pendidikan
Pasien bersekolah hingga lulus SD. Pasien berhenti sekolah karena masalah biaya
b. Riwayat Pekerjaan
Pasien bekerja bekerja sebagai buruh lepas di Kalimantan sekitar 5 tahun sesudah
lulus SD. Pasien bekerja di Kalimantan hingga lebih dari 10 tahun kemudian pindah
melanjutkan kerja di Jawa. Pasien berhenti bekerja 3 tahun yang lalu dan
menganggur di rumah
c. Riwayat Pernikahan
Pasien sudah menikah.

d. Riwayat Agama
Pasien dibesarkan dalam keluarga beragama Islam. Pasien merupakan orang yang
taat beragama.

e. Riwayat Psikoseksual
Pasien sejak kecil dipakaikan baju laki-laki dan hingga saat ini senang sebagai laki-
laki. Ketertarikan dengan lawan jenis dalam batas kewajaran. Tidak ada kelainan
dalam perkembangan seksual. Saat masih kanak-kanak pasien lebih suka bermain
dengan anak-anak laki-laki sebayanya.

f. Riwayat Aktivitas Sosial

Pasien memiliki hubungan yang baik dengan warga sekitar.

g. Riwayat Pelanggaran Hukum

Pasien tidak pernah memiliki riwayat pelanggaran hukum.

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h. Riwayat Keluarga
Pasien merupakan anak kedua dari 5 bersaudara. Pasien dibesarkan oleh ayah
dan ibunya sendiri di Magelang. Tidak ditemukan adanya gangguan jiwa dalam
keluarga.

Keterangan:
Pria Pria dengan Serumah
gangguan jiwa
Wanita Pasien Meninggal

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III. MENTAL STATUS EXAMINATION
A. General Description
1. Appearance
Appears a woman, age 40 years old, appropriate to the age, and dressed well.
2. Behaviour and psychomotor activity
Along the interview, patient look normal and focus.
3. Attitude
Cooperative and talk a lot.
B. Orientation
People : good Place : good
Time : good Situation : good
C. Consciousness
Clear
D. Pshycic contact
Present; equitable; constant
E. Behaviour
Normoactive
F. Attitude
Cooperative
G. Verbal
Increased (quantity), normal (quality)
H. Mood
Dysphoric
I. Perception
Hallucination (-), illusion (-)
J. Thought
1. Thought form : realistic
2. Thought content : normal
3. Thought process : coheren
K. Conversation
Patients speak with adequate volume and tend to speak calmly.
L. Insight
True insight

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 M. Attention Concentration
Easy to attract (+), sustainable concentration (+)
N. Attention Concentration
Level of education : junior high school
General knowledge : good
Orientation : good
Working/short/long memory : good
Ability to read & write : good
Ability to be independent : good
O. Impulsive Control When Examined
Self control : good
Patient respond : good

IV. PEMERIKSAAN DIAGNOSTIK LEBIH LANJUT

A. Status Internus

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 Keadaan umum : Tampak sehat Denyut nadi : 90x/mnt
Kesadaran : Compos mentis Frekuensi pernafasan: 20x/mnt
Tekanan darah : 150/90 mmHg Suhu: 36,6oC
Berat badan : 46 kg
Kepala : Mata anemis -/- sklera ikterik -/-
Leher : Struma (-), tekanan vena jugularis normal
Dada
- Jantung : BJ I-II tunggal, bunyi tambahan (-)
- Paru : Sonor, vesikuler (+) normal, ronkhi (-), wheezing (-)
Abdomen : Supel, nyeri tekan epigastrium (+), bising usus (+) normal, hepar dan
lien tak teraba
Ekstremitas : Akral hangat, kulit kering, edema -/-
Status lokalis
Lokasi : a/r aksial dextra sinistra at thoracal anteroposterior
Efloresensi : papul vesikel eritema berukuran milier hingga lentikuler, bentuk
bulat tidak berarturan, berbatas tegas, penyebaran diskret disertai
skuama, tepi lesi lebih aktif yang terdiri dari papul eritematosa dengan
susunan polisiklik.
B. Status Neurologik
Motorik : Tidak ada kelumpuhan, tonus baik
Sensorik : Dalam batas normal
Nervi Cranialis : Dalam batas normal
Refleks fisiologis : (+) Normal / (+) Normal
Refleks patologis : (-) / (-)
Kesan : tidak ada kelainan
V. RESUME
Mrs. M, 40 years old, appears appropriately to age, gender female, with good
activity daily living, ethnic Javanese, Islam, marital status, patients working, living in
Sumberejo, conducting examinations to see the mental health condition of patients. Came
to Mertoyudan 1 health center on July 29, 2019 by going alone.
From autoanamnesis found that since 2010 patients began to feel sad, easy to get
tired, continuous thoughts about the nature of both in-laws at home, difficulty sleeping and
waking up at night so they can not sleep anymore, and decreased appetite. In addition,

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patients also complain of nausea and dizziness that often occurs to him. The patient can
only surrender and continue to be patient with his current condition, regarding it as a test
from God.
VI. SYNDROME
 Sad Depression syndrome (main)
 Easy to fatigue
 Decreasing appettite Depression syndrome (additional)
 Sleep disturbing
 Nausea Gastritic syndrome
 Epigastric pain

VII. DIFFERENTIAL DIAGNOSIS

1. F 32.0 Mild depression
2. F 32.1 Moderate depression
3. F 43.2 Disruption of adaptation

VIII. MULTIAXIAL DIAGNOSIS

Axis I : F32.0 Mild depression
Axis II : no diagnosis
Axis III : Hipertension
Axis IV : Problem with mother in law
Axis V : GAF Current : 70-61, some mild & persistent symptoms, mild social
disability, are generally still good.

IX. PROBLEM RELATED

a. Biologic : neurotransmitter imbalance (serotonin) at the mesolimbic pathway
b. Psychopathology : dysphoric, losing appetite, sleep disturbance, fatigue
c. Social : avoiding to socialize with certain people in the same home

X. THERAPY
a. Respond phase
b. Maintenance phase
c. Remission phase

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 d. Recovery phase
 Metformin 3x500 mg
 Glucodex 2x80 mg

XI. PROGNOSIS
a. Pre-morbid
- History of psychiatric disorder in family : (-) good
- Marital status : (+) good
- Family support : (+) good
- Socioeconomic status : (-) poor
- Stressor : (+) poor
- Environment support : (-) poor
- Personality : Ekstrovert
b. Morbid
- Onset age : 31 years old
- Type of disorder : non-psychotic
- Organic disorder : (-) good
- History of disease : 9 years ago (poor)

 Quo ad vitam : dubia

 Quo ad functionam : dubia
 Quo ad sanactionam : dubia

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