Case Report Sessions

Friday/ January 08th, 2016

Recurrent Depressive Disorder, Currently in

Remision

By

: Joshua Hariara Pandiangan P1736A

Hengky Fandri

Preceptor

P1737A

: dr. Yaslinda Yaunin, Sp.KJ

DEPARTMENT OF PSYCHIATRI
MEDICAL FACULTY OF ANDALAS UNIVERSITY
GENERAL HOSPITAL OF M.DJAMIL PADANG
2015

I.

IDENTITY OF PATIENT
Name
: Ms. ZY
Sex
: female
Age
: 16 years old
Religion
: Moslem
Ethnic

: Minangkabau

Last education

: Elementary school

Job

: no job

Marriage

: single

Address

: Lubuk Alung

Handphone number

:-

Patient came to hospital for treatment on February 23 th, 2015,

accompanied by her mother.
II.

HISTORY OF PSYCHIATRI
Data was get by:
- Autoanamnesis on February 23th, 2015.
- Alloanamnesis to:
Mother (Jusnita) on February 23th, 2015
- Medical record.
A. Main Complain
Can not speak fluently since childhood
B. Recent History
- Initially, patient is difficult to communication since childhood,
slow responding, she seems does not understand the contents of
conversation. She should be asked clearly so she can follow the
orders. When talking she looks scared and confused.
- Patient only play with her cousins at home.
- Patient could help her mother to do daily activity such as cooking,
sweeping and washing.
- Eating and sleeping enough.
- Patient failed to the next grade two times in elementary school. She
only went to school until 5th grade.
- Patient can only mention the word mama, papa at the age of 6
years.
C. Previous History
1. Psychiatry disorder history
- Patient has no psychiatry disorder history.
2. Medical disorder history
- Febrile seizures repeatedly since the age of 20 days.

D. Private History
1. Prenatal/ Perinatal period
Patient was born as the 1st child of 2 siblings. Patient was born on
time and norm weight. The pregnancy was helped by indigenous
medical practitioner and cried.
2. Early pediatric period (0-3 years)
Prone on 3 months, crawl on 6 months and can walk on 14
months, but she could not say anything.
3. Middle pediatric period (3-11 years)
She can only mention the word mama, papa at the age of 6
years.
4. Late pediatric period and adolescence period
Patient grew and developed healthy like others, had no friends. The
patient got education until grade 5 elementary school.
E. Family History

patient

Explanation :

: Man
: Woman
: living with patient

F. Recent life situation

The patient lives with perents and brother in one house. Their
communication is disturbed.
G. Familys perception and hope
Family wanted the patient get well soon and continue her live.
H. Patients perception and hope
The patient wanted get well soon and continue her live.
III.

Internal Status
General Condition
Awareness
Blood pressure
Pulse

: not looks ill

: Composmentis
: 120/80 mmHg
: regular, strong
times/minute

lift,

frequency

83

Respiration

Temperature
Height
Weight
Nutritional status
Cardiovascular system
Inspection

times/minute
: Afebril
: 150 cm
: 50 kg
: well
:
: Ictus cordis not visible

Palpation

torachoabdominal,

frequency

21

: Ictus palpable around one finger medial to

left midclavicular line, 5th intercostal
space

Percussion : Up: 2nd intercostal space, left: one finger

medial to left midclavicular line, right:
dextra sternalis line
Auscultation:heart sound III and irregular heart sound,
murmurs absent
Respiratoric System

Inspection : Simetric statically and dinamically

Palpation

: Fremitus similar between left and right

chest

Percusion : Sonor all over the thorax

Auscultation: Vesicular breath sound present, ronchi
absent, wheezing absent
Specific abnormalities
IV.

Neurologic Status
GCS

: E4M6V5

Meningeal Sign

: absent

Extrapiramidal sign
-

Hand tremor
: absent
Akatisia
: absent
Bradikinesia
: absent
Way of stepping: normal
Balance
: non disturbed
Rigiditas
: absent
Motoric
:
freely in any direction
555
555
Sensorik
: well propioseptif and exteroseptif
555 555

V.

Refleks

: Phisiologic reflex (+), phatologic reflex (-)

Mental Status
Autoanamnesa
Pertanyaan
Jawaban
Siang dek. Ambo dokter Iyo

Interpretasi
Compos mentis

muda Trisno dan iko dokter

muda wiwi. Buliah kami
tanyo tanyo subanta dek?
Sia namo ?
Dari ma Zahra?
Apo yang taraso kini ko?

Zahara
Lubuak Aluang
Ibu menjawab
lambek

Personal orientation intact

:

mangecek

buk,kadang ngarati
kecek

awak,

kadang indak, nyo

baru

pandai

mangecek umua 6
Bara umuanyo kini buk?

tahun
16
Time orientation not

Tahun bara kini dek?

Bulan apo kini dek?
Tanggal bara kini ko dek?
Kecek ibuk adek susah

(diam)
(diam)
(diam)
Iyo

mangecek, iyo tu?

Manuruik adek patuik ndak Iyo
apak dibaok kamari?
Apak tau kini sadang dima?
Ado raso cameh dek?

Dirumah sakik
(diam)

jantuang berdebar-debar?
Ba a Zahra, ado raso takuik

(diam)

ka

urang?

insyaallah

kami
ka

disturbe
Discriminative insight
good
Discriminative judgment
good
Spatial orientation intact

disiko

manolong

Zahra, ndak usah cameh

yo..
Ngarati Zahra?
(Menggeleng)
Biasonyo dirumah Zahra Nolong
ibu,
manga?

mambarasiahan
rumah, mamasak.

Abulia (-)

Ado mancaliak bayangan-

(diam)

Visual halutination (cannot

bayangan?
Kalau raso diraba-raba atau

(diam)

be evaluated)
Tactil halutination (cannot

dipegang?
Ado membau-bau sesuatu (diam)

be evaluated)
Olfactory halutination

yang busuak tapi ndak jaleh

(cannot be evaluated)

dari ma asalnyo?
ado maraso dandam atau (diam)

Animosity/revenge (canot

banci ka urang ndak pak?

Pernah
maraso
ndak (diam)

be evaluated)
Inferior feeling (canot be

baguno?
Makasih yo, beko diperikso yo

evaluated)

samo dokternyo yo
Makasih y buk

Based on the examination in February, 23th 2015

I. General Condition
Awareness

: Composmentis

Attention

: less

Attitude

: Cooperative

Inisiative

: less

Motoric behaviour

: hypoactive

Facial expression

: poor

Speech and verbal

: speak less and not clearly

Physical contact

: can be done, natural, and short-time

II. Spesific condition

A. Natural State of Feeling
1. Afective condition : hipothym
2. Emotion Living

: a. Stability

: stabile

b. Control

: controlled

c. ech unecht

: echt

d. einfuhlung ( invoelaarhaid )

: adequate

e. deep-shallow

: shallow

f. differentiation scale

: wide

g. emotion flow

: slow

B. Intelectual Function
a. Memory (amnesia)

: can not evaluated

b. Concentration

: inadequate

c. Orientation
( time, spatial, personal, situation)

: can not evaluated

d. general knowledge

: can not evaluated

e. discriminative insight

: good

f. alleged level of intelegency

: can not evaluated

g. discriminative judgment

: good

h. intelectual deterioration

: absent

C.Perseption and sensation anomaly

a. illution
b.halutination

: can not evaluated

- acustic

: can not evaluated

- visual

: can not evaluated

- olfatorik

: can not evaluated

- tactil

: can not evaluated

D. Way of Thingking
1. Psikomobilitas

: slow

2. Thingking process
a. clear and sharp

: not clear and not sharp

b. Sirkumstansial

: can not evaluated

a. Inkoherrent

: can not evaluated

b. Sperrung

: can not evaluated

c. Hemmung

: can not evaluated

d. Flight of ideas

: can not evaluated

e. Verbigerasi Persevarative ( Persevaratich )

: can not evaluated

3. Contents
a. Central pattern

: can not evaluated

b. Phobia

: can not evaluated

c. Obsess

: can not evaluated

d. Dellusion

: can not evaluated

e. Suspicion

: can not evaluated

f. Confabulation

: can not evaluated

g. Animosity/revenge

: can not evaluated

h. Inferior feeling

: can not evaluated

i. Much/less

: less

j. Guilty feeling

: can not evaluated

k. Hippochondria
l. Others

: can not evaluated

:-

E. Instinctual impulse disorders

a. Abulia

: absent

b. Stupor

: absent

c. Raptus / impulsivitas

: absent

d. excitement state

: absent

e. sexual deviation

: absent

f. Echophraxia

: absent

g. Vagabondage

: absent

h. Piromani

: absent

i. Mannerisme

: absent

j. Others

:-

F. Overt anxiety

: can not evaluated

G. Relation to reality

: can not evaluated

VI. Multiaxial Evaluation

Axis I. Clinical Syndrome
Can not speak fluently since childhood
General condition: cooperative, passive, speaking less and not clearly, psychic
contact can be done for short duration of time, attention less.
Specific condition

Natural state of feeling : hypothym, stabile, good controlling, echt,

adequate einfuhlung, shallow, wide differentiation scale, slow emotion

flow
Intellectual condition : memorizing abililty can not evaluate, concentrarion
inadequate, orientation can not be evaluated, general knowledge can not be
evaluated, discriminative insight good, allegged level of intelegency can
not evaluated, discriminative judgment good, intellectual deterioration

absent
Sensation and perception disorder: illusion and hallucination can not

evaluated.
Process of Thinking: slow, not clear and not sharp, circumstancial can not
evaluated, incoherrent can not evaluated, Sperrung can not evaluated,
Hemmung can not evaluated, flight of ideas can not evaluated,
verbigeration can not evaluated, central pattern can not evaluated, phobia
can not evaluated, delusion can not evaluated, suspicion can not evaluated,
confabulation can not evaluated, animosity and revenge can not evaluated,
inferior feeling can not evaluated, content less, guilty feeling can not

evaluated, hypochondria can not evaluated.

Instinctual encouragement: abulia absent, stupor absent, raptus absent,
excitement state absent, sexual deviation absent, echophraxia absent,

vagabondage absent, pyromania absent, mannerisme absent.

Anxiety: can not evaluated
Relation to reality: can not evaluated

Axis II. Personality disorder and mental retardation

IQ test score of patient is 57.
Axis III. General Medical Condition
No history of head trauma, malaria, typhoid, and other disease which
needs hospitalization. No history of alcohol and drugs consumption.
Axis IV. Psychosocial and environment
No diagnosis
Axis V. Global Assessment of Functioning
40-31: multiple disabilities in touch with reality and communication,
severe disability in some functions

MULTIAXIAL DIAGNOSIS
I.
F80.1 Expressive language disorder
II.
F20. Mild Retardation Disorder
III.
No diagnosis
IV.
No diagnosis
V.
GAF 40-31
DIFFERENTIAL DIAGNOSIS
1. F80.8 Others Speech and language development disorders
2. F80.9 Speech and language development disorders are not classified
THERAPY
A. Pharmacotherapy :

Piracetam 2 x 400mg
Ginkoforce 2x1 tab
Vitamin B1 2 x 10 mg
Vitamin C 2 x 1 tab

B. Psychotherapy :
1.

Patient
Supportif psycotherapy
Psychoeducation
2. Family : Psychoeducation about
Patient disorder
Teraphy
PROGNOSIS
Quo ad vitam
: dubia ad
Quo ad fungsionam : dubia ad
Quo ad sanactionam : dubia ad
XII. CASE ANALYSES
The diagnosys of the patient got from history and physical
examination. Patients main complains is can not speak fluently since
childhood. Physical examination shows normal blood pressure of 120/80
mmHg. Cardiovascular, respiratory, gastrointestinal, and neurologic
examination shows no abnormalities.
Initially, patient is difficult to communication since childhood, slow
responding, she seems does not understand the contents of conversation. She
should be asked clearly so she can follow the orders. When talking she looks

scared and confused. Patient only play with her cousins at home. Patient can only
mention the word mama, papa at the age of 6 years. Patient failed to the next
grade two times in elementary school. She only went to school until 5th grade
- Patient could help her mother to do daily activity such as cooking,
-

sweeping and washing.

Eating and sleeping enough.

He was taken to RSUP M. Djamil

Patient had febrile seizures repeatedly since the age of 20 days.
Psychic contact can be done, natural, persist for short duration, hypothym,
stabile, good controlling, echt, shallow, narrow differentiation scale, slow emotion
flow, Intellectual function can not evaluated. Discriminative insight and
discriminative judgement good, Sperrung, Hemmung cannot evaluated.
Patient is diagnosed with xpressive language disorder as stated in the PPDGJIII. Patient is given Piracetam 2 x 400mg, ginkoforce 2x1 tab, vitamin B1 2 x 10
mg, vitamin C 2 x 1 tab.

SCHEME OF DISEASE HISTORY

On 2000, the
patients father died.
Patient more often
dreamy, moody, and
suddenly cried own.
Patient locked
himself in the room.
Patient are not taken
for treatment by his
family.

On 2009, his
mother was died.

On 2003, the
patient suddenly
left the house and
went without a
clear purpose. He
left his wife. He
more often dreamy,
moody, and
suddenly cried.

On 2014, he
rampage and
angry because of
his desire to
marry again not
release. He was
taken to RSUP
M. Djamil and
treated for 25
days.

2015. Initially, patient was asleep,

then patient heard voice of
television and water while his
young sister was washing. Patient
rampage and told his young sister to
turn off television and water. After
that, the patient laughed and
suddenly cried. Patient intending to
burn his home because get
headache after the incident earlier.
He was taken to RSUP M. Djamil