MINI CEX

NON-PSICOTIC

Oleh :
Mirantika Audina I4061172033

Pembimbing:
dr. Sabar Parluhutan Siregar, Sp.KJ

FAKULTAS KEDOKTERAN
UNIVERSITAS TANJUNGPURA
2018
IDENTITY

Patient’s Identity Relative Identity

• Name : Mrs. ZA • Name : Mr. K
• Age : 30 years old • Age : 58 years old
• Gender : Female • Gender : Male
• Address : Magelang • Address : Magelang
• Religion : Moeslem • Occupational : Pension
• Ethnic : Java • Relation : Biological Father
• Marital Status : Married • Intimacy : Close
• Occupational : Housewife
• Education : Senior High School
• Date of Entry : October 14th,
2018
• Date of examination :
October 14th, 2018
ANAMNESIS

The reason why patient was bring to the hospital

Patient bring to hospital because she did not sleep for 3 days and
like to hit her head on the wall
ANAMNESIS
Present story of patient illness :

• Alloanamnesis
From alloanamnesis with her father found that patient was
bring to mentol hospital Prof. dr. Soerojo Magelang
because the patient has not been sleeping for 3 days and
like to hit her head into the wall. She also become more
quite after her problem with her husband and did not
sociate with her neighbour again. She also had decreasing
of appetite. About 20 days ago, her second child was died
and it made her behavior change, such as she ever tried to
burn diapers in her home and threw her clothes outside of
the house. She ever tried to kill herself, sometimes she still
think that her second child still alice. She did not wanna do
anything and just daydreaming all day
ANAMNESIS
Present story of patient illness :

• Autoanamnesis
From autoanamnesis, patient said that she feel unhappy
and she didnt wanna do anything. She also said that her
second child still alive but live with her husband. She said
that she became frustrated that her husband work so much
and they dis not spend time alone. She also said had
difficulties in sleeping. This condition occure isnce her
relationship with her husband became bad.
ANAMNESIS
History of Illness :
• Psychiatric disorder :
Patient ever hospitalized in mental hospital in Jakarta for one time
• General medical illness disorder :
there was no chronic illness disorder or head trauma or seizure
• Substance abuse :
History of smoking (-), alcohol use (-), drug abuse (-)
ANAMNESIS
History of Personal Life :

• Prenatal and Perinatal

There is o valid data.
• Early Childhood Phase :
There is no valid data
• Intermediate Childhood Phase :
There is no valid data
• Late Childhood and Teenager Phase :
There is no valid data
ANAMNESIS
• Adulthood Phase
- Education : patient just studied till Senior High School
- Occupational : housewife
- Marital staus : married, seince 2 years ago, her parents
decrease giving her care and flirt with other girl. He also had
some loans using patirnt name. About 20 days ago, her last
children was passed away
- Criminal : patinet has no criminal history but she ever tried to
suicide
- Social activity : Patient haven’t a close friend sine she was a
child. Psycosocial : Patient have a normal relationship with his
parent and sibling. But sometimes not friendly with his family.
- Current situaton : Patient lived with his parent.

Family History :
There is no history of same symptoms in his family
PEMERIKSAAN FISIK
Status Internus
KU : Baik TD : 122/82 mmHg RR : 20 x/menit
Kesan : Compos mentis HR : 80 x/menit T : 36,8OC

Kepala Normocephal

CA(-/-), SI (-/-), pupil reguler bulat isokor 3 mm/3 mm, refleks cahaya
Mata
(+/+)

Mulut Bibir sianosis (-), mukosa bibir kering (-), atrofi papil lidah (-)

Leher Bentuk simetris, ↑JVP (-), pembesaran KGB (-)

Statis, bentuk dada simetris, kelainan kulit (-). Dinamis, gerakan paru
Inspeksi simetris, tidak ada gerakan paru yang tertinggal, penggunaan
otot bantu pernapasan (-)

Paru Palpasi Fremitus taktil paru kanan = paru kiri, nyeri tekan (-)

Perkusi Sonor dikedua lapang paru

Suara napas dasar: vesikuler (+/+). Suara napas tambahan: wheezing (-
Auskultasi
/-), ronkhi (-/-)
PEMERIKSAAN FISIK
Status Internus
Jantung Inspeksi Iktus kordis tidak terlihat
Palpasi Iktus kordis tidak teraba
Perkusi Batas kanan jantung: SIC IV linea parasternal dextra
Pinggang jantung: SIC III linea parasternal sinistra
Batas kiri jantung: SIC V linea midclavicularis sinistra
Auskultasi S1/ S2 reguler, murmur (-), gallop (-)
Abdomen Inspeksi Distensi (-), sikatrik (-)
Auskultasi Bising usus (+) 6x/menit
Perkusi Timpani
Palpasi Supel (+), hepar dan lien tidak teraba, nyeri tekan (-),
massa tidak teraba
Ekstremitas Akral hangat, CRT <2”, edema (-/-)

Kesimpulan dalam batas normal

PEMERIKSAAN FISIK
Status Neurologis
Motorik : Tonus normal, koordinasi gerakan baik, eutrofi,
kekuatan motorik 5/5/5/5
Meningeal sign : negatif
Refleks fisiologis : +/+
Refleks patologis : -/-
Sensorik : Dalam batas normal

Kesimpulan dalam batas normal

MENTAL STATUS EXAMINATION
General Appearance :
A female, 30 years old, appropriate to her age, good enough for
self care, were complete and clean clothes
Orientation (P/T/P/S) : Good
Psycis contact : Present, euitable, constant.
Behavior : Hypoactive
Verbal :
- Quantity : decreased
- Quality : normal
Mood : Irritable
Affect : blunted, appropriate
Perception :
- Hallucination (-)
- Illusion (-)
- Depersonalization (-)
- Derealization (-)
MENTAL STATUS EXAMINATION
Thouhgt of Process :
- Quality : Coheren
- Quantity : Blocking
Thouht of Content :
Idea of suspicion
Thought Form :
Non-realistic
Insight : Impaired insight
Attention Connection :
Attention not good, unable to sustained concentration
MENTAL STATUS EXAMINATION
Sensorium and Cognitive :
- Level of education : good
- General knowledge : good
- Orientation : moderate
- Woring/Short/Long memory : moderate
- Ability to read and write : good
- Ability to independent : moderate
Impulsive control when examine :
- Self control : enough
- Patient respons : enough
DIAGNOSIS
Depressive syndrome :
- Hypoactive
- Irritable mood
- Anhedonia
- Anenergy
- Sleep disorder
Paranoid syndrome :
Idea of suspicion

DIAGNOSIS BANDING
F45.3 Severe Depression Episode (202)
Depressive Disorder
F32.3 Severe Deoression Episode without psychotic
sympony
DIAGNOSIS MULTIAKSIAL
AKSIS I : F45.3 Severe Depression Episode (202)
Depressive Disorder
AKSIS II : Pending
AKSIS III : No diagnosis
AKSIS IV : Primary Support Group
AKSIS V : 50 – 11 currently
MANAGEMENT PLANNING
Patient need to hospitalized
Maintenance therapy :
Fluoxetin 10 mg/24 hours
Risperidon 2 mg/12
Trihexyphenidil 2 mg 2x2
Psycotheray :
- Behavior management
- The patient need family support
- Explain that environment, neightborhood, family situation
assocaited to the disorder.
PROGNOSIS
Quo ad vitam : bonam
Quo ad functionam : Dubia ad bonam
Quo of sanactionam : Dubia ad malam
THANK YOU