Cbd Non Psikotik.pptx

CASE BASED DISCUSSION

NON-PSYCHOTIC

Supervisor : dr. Sabar Parluhutan Siregar, Sp.KJ Oleh : Andi Yusrizal Itqi Rahmatul Laila Rizka Ulfatin Arifah

20174011081 20174011157 20174011170

Patient Identity

▸ ▸ ▸ ▸ ▸ ▸ ▸ ▸ ▸ ▸

Name

: Mrs. NH

Age

: 55 years

Gender

: Woman

Address

: Dompyong, Temanggung

Ethnic

: Javanese

Religion

: Moslem

Education

: Senior High School

Job

: Housewife (Restaurant owner)

Marital Status

: Married

Date of examination

: 5th May 2018

“

Identity (Alloanamnesis)

There was no valid data from the alloanamnesis

ANAMNESIS

MAIN PROBLEM The patient had an over anxiety about being sick and suggested by an internist to check to psychiatry

HISTORY OF PRESENT ILLNESS ▸ Autoanamnesis : The patient was going to polyclinic of Psychiatric Hospital Prof. Dr. Soerojo Magelang because she has an over anxiety about being sick since about 6 months ago.

Cont..

▸ The patient feels anxiety when ▸ She thinks about her illness especialy hypertension ▸ Holding back bowel movement ▸ Satiety ▸ Wake up late

Cont..

▸ What happens when the patient feels anxiety ▸ Feels easily surprised ▸ Difficult to sleep FAKTOR PREDISPOSISI ▸ Trembling ▸ Pounding ▸ Fatigue ▸ Heavy breath

Cont..

The patient has been hospitalized because her blood pressure reach 190/100 mmHg. The other examination beside her blood pressure was normal, but she start afraid about her illness since that August 2017

October 2017

October 2017

Patient was brought to the emergency departement because she complaint about dyspneu, pounding, headache, and trembling. Her blood pressure at that time is 220/120 mmHg. Her ECG result and other examination results are normal. August 2017

October 2017

October 2017

The patient feels anxious because she got drugs once in a day and thinks it’s not enough. The patient consulted to psychiatry and diagnosed as general anxiety disorder and always control her illness

August 2017

October 2017

October 2017

HISTORY OF PAST ILLNESS ▸ Psychiatry disorder: • Patient always control routinely in polyclinic of RSJS since •

October 2017 Patient alwyas consume her medications Sertraline 50 mg 1-0-0 Trifluoperazine 5 mg 0-0-1 Lorazepam 2 mg 0-0-1

Cont..

▸ General medical illness • Patient has diagnosed with hypertension since August

▸

2017 and has been hospitalized three times • High fever, seizure, head trauma, allergy, or another chronic disease denied. Substance abuse There’s no history of smoking, alcohol use, or drug abuse

HISTORY OF PERSONAL LIFE ▸

Prenatal and Perinatal Phase • The patient was the seventh child of seven children • There’s no valid data in patient’s prenatal aspect (ANC, age, condition when pregnant such as hypertension, weight gain when pregnant of immunization status before and when pregnant) • There’s no valid data in patient’s perinatal aspect (APGAR score, difficultines during labor or patient’s condition during birth, and immunization status

• Early Childhood (0-3 years old) • There’s no valid data in patient. • Masa kanak akhir (11-18 th) Pasien semakin menutup diri setelah mengalami gangguan jiwa saat kelas 1 SMP dan memutuskan untuk berhenti sekolah.

ADULTHOOD ▸

Education Patient graduated from senior high school with quite good score.

▸

Occupational After graduated from senior high school, patient work as a model with Basuki Abdullah for two years, than she run the restaurant

▸

Marital Status Patient has beed married 3 times, last time she divorced 2014

Cont..

▸

Religion Patient is a moslem and doing prayer 5 times a day routinely

▸

Current living situation Patient lives alone at his home

▸

Family Relationship Patient is the youngest child from 7 siblings, she dominantly close with her mother and her big brother who has beed passed away

Cont..

▸

Understand and self awareness Patient feels that her mental problem is not a normal condition

▸

Responsibility in medicine Patient is consume her medicine routinely

FAMILY HISTORY OF ILLNESS ▸ Psychiatric Disorder Patient’s 4th big sister also have symptomps like her ▸ General Medical Illness Patient’s mother and 5th big brother had passed away because of stroke and her mother also had hypertension

GENOGRAM Legends: Patient Female

Male Die Physical Illness Psychiatry Illness Live Together Divorced

Symptoms

Okt 2017

Role of Function

CURVE PROGRESSION OF ILLNESS

Mei 2018

PHYSICAL EXAMINATION

INTERNAL STATUS ▸ Conciousnes ▸ Vital Sign Blood Pressure Heart Rate Respiration Rate Temperature

: Compos mentis E4V5M6 : 130/90 mmHg : 72 x/minute : 22 x/menit : 36,5° C

HEAD ▹ Head ▹ Eyes ▹ ▹ ▹ ▹

Nose Ears Mouth Neck

: normocephali : conjungtival anemi-/-, icterous sclera -/: secrete -/: normotia/normotia, secrete -/: sianosis (-) : lymphnode enlargement (-)

Thorax

In normal range

Abdomen In normal range Urogenital In normal range Ekstremitas In normal range

PEMERIKSAAN NEUROLOGIS ▸ GCS ▸ Kaku kuduk ▸ Saraf kranialis I - XII

: E4 V5 M6 : Tidak ditemukan : Tidak ada penemuan

▸ ▸ ▸ ▸

: Tidak dilakukan pemeriksaan : Tidak dilakukan pemeriksaan : Tidak dilakukan pemeriksaan : 5 5

bermakna Refleks fisiologis Refleks patologis Sensorik Motorik

5 5

PEMERIKSAAN STATUS MENTAL

a. Deskripsi Umum Sikap dan tingkah laku Tanda jenis kelamin Pakaian dan kerapihan Perhatian dengan pemeriksa a. Afek Keserasian Konsistensi a. Mood

: kooperatif, normoaktif : perempuan sesuai usia : rawat diri baik dan berpakaian : mudah ditarik mudah dicantum : apropriate : stabil : eutimik

a. b. c. d.

Bentuk pikir Gangguan persepsi Isi pikir Progresi pikir Kuantitatif Kualitatif a. Orientasi W/T/O/S

: Realistik : disangkal :

Tilikan diri

:5

: normal : normal : baik/baik/baik/baik

FORMULA DIAGNOSIS Sindrom yang didapatkan dari pemeriksaan : ▸ Sindrom Cemas ▹ Rasa gemetar ▹ Tidak bisa diam ▹ Nafas pendek/berat ▹ Jantung berdebar-debar ▹ Kepala pusing/rasa melayang ▹ Mudah terkejut/kaget ▹ Sukar tidur

DIAGNOSIS ▸ F41.1 (Generalized Anxiety Disorder)

“ a.

F41.1 Gangguan Cemas Menyeluruh

Pedoman Diagnostik Menurut PPDGJ – III

Kondisi Pada Pasien

Penderita harus menunjukkan anxietas sebagai gejala primer yang berlangsung hampir setiap hari untuk beberapa minggu sampai beberapa bulan, yang tidak terbatas atau hanya menonjol pada keadaan situasi khusus tertentu saja (sifatnya “free floating” atau “mengambang”)

b.

Gejala-gejala tersebut biasanya mencakup unsur-unsur berikut:

c.

Pada anak-anak sering terlihat adanya kebutuhan berlebihan untuk ditenangkan (reassurance) serta keluhan-keluhan somatik berulang yang menonjol

d.

Adanya gejala-gejala lain yang sifatnya sementara (untuk beberapa hari), khususnya depresi, tidak membatalkan diagnosis utama Gangguan Anxietas Menyeluruh, selama hal tersebut tidak memenuhi kriteria lengkap dari episode depresif (F32.-). Gangguan anxietas fobik (F40.-), gangguan panik (F41.0), atau

gangguan obsesif-kompulsif (F42.0)

Terpenuhi

DIAGNOSIS MULTIAKSIAL ▸ Axis I ▸ Axis II ▸ Axis III ▸ Axis IV ▸ Axis V

: F 41.1 Gangguan cemas menyeluruh : Z03.2 : Hipertensi : Masalah berkaitan kondisi kesehatan : GAF 80-71

TERAPI

▸

Psikoterapi ▹ Pengenalan terhadap penyakitnya, manfaat pengobata, cara pengobatan dan efek samping pengobatan ▹ Memotivasi pasien gar minum obat secara teratur dan rajin kontrol setelah pulang dari perawatan ▹ Membantu pasien untuk dapat kembali melakukan aktivitas sehari-hari secara bertahap ▹ Membantu pasien untuk lebih mendekatkan diri kepada Allah

TERAPI ▸ FARMAKOLOGI Sertraline 50 mg Trifluoperazine 5 mg Lorazepam 2 mg

1-0-0 0-0-1 0-0-1

36

PROGNOSIS No.

Faktor-Faktor

Pada Pasien

Baik

Buruk

Faktor Premorbid 1.

Riwayat gangguan jiwa pada keluarga

Ada



2.

Status pernikahan

Cerai



3.

Dukungan keluarga

Ada



4.

Dukungan sosial

Ada



5.

Status Ekonomi

Menengah Keatas



6.

Stressor

Ada



37

No.

Faktor-Faktor

Pada Pasien

Baik

Buruk

Faktor Morbid

8.

Onset

54 tahun



9.

Jenis penyakit

GAD



10.

Onset usia < 20 tahun

11.

Respon terapi

Baik



12.

Kepatuhan minum obat

Patuh



13.

Penyakit Organik

Tidak ada





38

Ad Vitam Ad Fungsionum Ad Sanationam

: dubia ad bonam : dubia ad bonam : dubia

39

DAFTAR PUSTAKA Muslim, Rusdi. 2007. Penggunaan Klinis Obat Psikotropik. Bagian Ilmu Kedokteran Jiwa FK Unika Atma Jaya. Jakarta Muslim, Rusdi,. 2003. Buku Saku DIAGNOSIS GANGGUAN JIWA.Jakarta: PT Nuh Jaya

THANKS