CASE BASED DISCUSSION

NON PSYCHOTIC

SUPERVISOR:
dr. Sabar P. Siregar, Sp. KJ

MENTAL HEALTH SCIENCE CLINICAL WORK

16thNovember– 18th December 2015
PROF. DR. SOEROJO MENTAL HOSPITAL
FACULTY OF MEDICINE TANJUNGPURA UNIVERSITY
 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
 Alloanamnesis
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
Autoanamnesis
 History also obtained from autoanamnesis in December
9th 2015 in patient’s house
The Reason Brought to Mental Hospital

The patient was brought to RSJ Prof. Soerojo Magelang

by her family on December 7th, 2015 because she often
felt her heart was pounding since 15 month ago.
 Progression of Illness

 Five years ago (In 2010), her husband was very angry
with her brother and wanted to kill her brother. Her
husband fought with a big knife in his hand. The patient
has changed behavior after seeing this. The patient was
very frightened and felt shock. She was very sad.
 Progression of Illness (cont’)
 The scene was played in her mind repeatedly and she
couldn’t erase that memories. Everytime she
remembered that scene, her heart began to beat so
fast. She couldn’t sleep well and hard to concentrate.
She got lost of pleasure. She had no appetite to eat. She
often felt dizzy so she just lay in bed. She got lost her
energy and quited from her job. Her self care was still
good.
 Progression of Illness (cont’)

 The patient avoided 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.
 If her children didn’t tell her about their condition, she
often felt worried.
 Progression of Illness (cont’)

 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 was hopeless. She
went to the hospital and had ECG and
thorax rontgen but the doctors said that
she was just fine.
Progression of Illness (cont’)

 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 his death.
 In 2015, one of her family suggested her
to go to RSJS Magelang and she visited
psychiatric policlinic routinely. She felt
better and she started to work as a labor
again.
Stressor
 Her husband was fighting with her brother
 The death of her husband
 History of Past Illness
medis
Psychiatric General medical Substance
illness illness abuse
There was no
She never history of high
opname at the The patient has
fever, seizure,
hospital and no history of
head trauma,
visited subtance abuse
any other
psychiatric like drugs,
systemic
policlinic alcohol, and
disease,or any
routinely every smoke.
other serious
month. illness which
needs
hospitalization.
History of Personal Life

1. Prenatal and Perinatal History

2. Early childhood phase
3. Intermediate childhood
4. Late childhood
5. Adulthood
 History of Personal Life (Cont’)

Prenatal and Perinatal Period

- She has two older sisters
Patient is a third child. - She has one younger brother
and four younger sisters

 Her mother age was 36 years old when she was pregnant and her
condition was well. The delivery was assisted by traditional birth
helper. She was spontanity and normality of delivery.
 There was no valid data about the condition of patient when she was
born such as activity (muscle tone), pulse, grimace (reflex
irritability), appearance, and respiration (APGAR score)
 There was no valid data about feeding habits of patient, is it breast
feed or bottle feed,
 Developmental History (Gross
Motoric)
Ability Result Normal range

Elevating the head No Valid Data 0-3 months

Moving to supine No Valid Data 3-6 months

position on its own
Sitting No Valid Data 6-9 months

Standing No Valid Data 9-12 months

Walking No Valid Data 12-24 months

Climbing up the No Valid Data 24-36 bulan

ladder
Standing 1 foot / No Valid Data 36-48 bulan
jump
 Developmental History (Fine Motoric)
Ability Result Normal range

Holding a pencil No Valid Data 3-6 months

Holding 2 objects at the same No Valid Data 6-9 months

time
Piling 2 cubes No Valid Data 9-12 months

Inserting objects into No Valid Data 12-18 months

container
Rolling a ball No Valid Data 18-24 months

Doodling No Valid Data 24-36 months

Wearing shirt No Valid Data 36-48 months

 Developmental History (Language)
Ability Result Normal range
Oooh-aah No Valid Data 0-3 months
Turning toward the sound No Valid Data 3-5 months

High-pitched sound No Valid Data 3-6 months

Voice without meaning No Valid Data 6-9 months
(mamama, Bababa)
Calling 2-3 syllables without No Valid Data 9-12 months
meaning
Calling 3-6 words that have No Valid Data 18-24 months
meaning
Talking at least with two words No Valid Data 24-36 months
Mentioning name, age, and place No Valid Data 36-48 months
 Developmental History (Social & Personal)
Ability Result Normal range
Know their mother No Valid Data 0-3 months
Reach out No Valid Data 3-6 months
Clap No Valid Data 6-9 months

Playing peek a boo No Valid Data 6-9 months

Know their family No Valid Data 9-12 months

Appoint what he wants No Valid Data 12-18 months
without crying or whining
Tidy up toys No Valid Data 24-36 months
Playing with friends, follow No Valid Data 36-48 months
the rules of the game
 Intermediate Childhood (3-11 years old )

Psychomotor (NO VALID DATA)

No valid data on when patient first time climbing the tree or play hide and
seek games, and if patient ever involved in any kind of sports.
Psychosocial
Patient first entered primary school when she was 7 years old. But she
didn’t passed the primary school. There was no valid data on patient’s
gender identification, interaction with his surrounding. how well patient
handle separation from parents, how well she plays with new friends on
first day of school
Communication (NO VALID DATA)
There was no valid data regarding patient’s ability to make friends in school,
and how many friends patient have during her schooling period.
Emotion (NO VALID DATA)
No valid data on patient adaptation under stress
Cognitive

 The patient’s grades in school was good and has ordinary achievement at
school.
 Late Childhood and Teenage Phase

Sexual Development Sign and Activity (NO VALID DATA)

No data on when patient first menstruation, growth hair on armpits, growth
pubic hair, etc.
Psychomotor (NO VALID DATA)
No data if patient had any favorite hobbies or games, if patient involved in any
kind of sports.
Psychosocial ( NO VALID DATA)
No valid data on when and how patient’s relationship with different gender, if
patient ever had any relationship with opposite gender.
Communication
The relationship between patient with parents is well. She had a closer
relation to her dad. She liked to share her feelings with her younger sister.
Emotion (NO VALID DATA)
No data if patient ever told friend or family regarding any problems
No data if patient attempted to break the rules (truant school subject, fight
with friends, bullying, ect) and consuming alcohol, smoke and drugs
Piaget's Stages of Cognitive Development

Stage Age Description Result

Sensorimotor 0-2 yrs •During this first stage, children learn entirely No Valid Data
through the movements they make and the
sensations that result. They learn:that they exist
separately from the objects and people around
them
•that they can cause things to happen
•that things continue to exist even when they
can't see them

Preoperational 2-7 yrs Once children acquire language, they are able to No Valid Data
use symbols (such as words or pictures) to
represent objects. Their thinking is still very
egocentric though -- they assume that everyone
else sees things from the same viewpoint as they
do.They are able to understand concepts like
counting, classifying according to similarity, and
past-present-future but generally they are still
focused primarily on the present and on the
concrete, rather than the abstract.
 Piaget's Stages of Cognitive Development
(Cont’)
Stage Age Description Result

Concrete 7-11 yrs •At this stage, children are able to see things from No Valid Data
Operational different points of view and to imagine events that
occur outside their own lives. Some organized,
logical thought processes are now evident and they
are able to:order objects by size, color gradient,
etc.
•understand that if 3 + 4 = 7 then 7 - 4 = 3
•understand that a red square can belong to both
the 'red' category and the 'square' category
•understand that a short wide cup can hold the
same amount of liquid as a tall thin cup
However, thinking still tends to be tied to concrete
reality

Formal 11+ yrs Around the onset of puberty, children are able to No Valid Data
Operational reason in much more abstract ways and to test
hypotheses using systematic logic. There is a much
greater focus on possibilities and on ideological
issues.

Physical
Physically active
Rule of Three: 3 yrs,3 ft, 33
lbs.
Weight gain: 4-5 lbs per
year
Growth: 3-4 inches per year
Physically active, can’t sit
still for long
Clumsy throwing balls
Refines complex skills:
hopping, jumping,
climbing, running, ride
“bigwheels” and tricycles
Improving fine motor skills
and eye-hand coordination:
cut with scissors, draw
shapes
3– 3,5 yr: most toilet
trained
Preschool
Cognitive
Ego-centric, illogical, magical thinking
Explosion of vocabulary;
learning syntax, grammar;
understood by 75% of people by age 3
Poor understanding of time,
value, sequence of events
Vivid imaginations; some
difficulty separating fantasy
from reality
Accurate memory, but more
suggestible than older children
Primitive drawing, can’t
represent themselves in drawing till age 4
Don’t realize others have
different perspective
Leave out important facts
May misinterpret visual cues of emotions
Receptive language better
than expressive till age 4
Social
Play:
Cooperative,imaginative, may
involve fantasy and imaginary
friends, takes turns in games
Develops gross and fine
motor skills; social skills;
experiment with social
roles;reduces fears
Wants to please adults
Development of conscience:
Incorporates parental
prohibitions; feels guilty when
disobedient; simplistic idea of
“good and bad” behavior
Curious about his and other’s
bodies, may masturbate
No sense of privacy
Primitive, stereotypic
understanding of gender roles
 Preschool (cont’)
Emotional Possible effects of maltreatment
Self-esteem based on what others tell him Poor muscle tone, motor coordination
or her Poor pronunciation, incomplete sentences
Increasing ability to control emotions; less Cognitive delays; inability to concentrate
emotional outbursts Cannot play cooperatively; lack curiosity, absent imaginative and
Increased frustration tolerance fantasy play
Better delay gratification Social immaturity: unable to share or negotiate with peers; overly
Rudimentary sense of self bossy, aggressive, competitive
Understands concepts of right and wrong Attachment problems: overly clingy, superficial attachments, show
Self-esteem reflects opinions of little distress or over-react when
significant others separated from caregiver
Curious Underweight from malnourishment; small stature
Self-directed in many activities Excessively fearful, anxious, night terrors
Reminders of traumatic experience may trigger severe anxiety,
aggression, preoccupation
Lack impulse control, little ability to delay gratification
Exaggerated response (tantrums, aggression) to even mild stressors
Poor self esteem, confidence; absence of initiative
Blame self for abuse, placement
Physical injuries; sickly, untreated illnesses
Eneuresis, encopresis, self stimulating behavior –rocking, head-
banging
 School Aged
Physical Cognitive Social

Slow, steady growth: 3 Use language as acommunication tool Friendships are situation
-4 inches per year Perspective taking: specific
Use physical activities 5-8 yr: can recognize others’ Understands concepts
to develop gross and perspectives, can’t assume the role of of right and wrong
fine motor skills the other Rules relied upon to
Motor & perceptual 8–10 yr: recognize difference between guide behavior and play, and provide child
motor skills better behavior and intent; age with structure and security
integrated 10-11 yr: can accurately 5-6 yr: believe rules can
10-12 yr: puberty recognize and consider be changed
begins for some others’ viewpoints 7-8 yrs: strict adherence
children Concrete operations: to rules
Accurate perception of 9-10 yrs: rules can be
events; rational, logical negotiated
thought; concrete thinking; reflect upon Begin understanding social roles; regards
self and attributes; understands concepts them as inflexible; can adapt behavior to fit
of space, time, dimension different situations; practices social roles
Can remember events Takes on more responsibilities at home
from months, or years Less fantasy play, more
earlier team sports, board games
More effective coping skills Morality: avoid punishment; self interested
Understands how his exchanges
behavior affects others
 School Aged (cont’)
Emotional
Self esteem based on ability to
perform and produce
Alternative strategies for dealing
with frustrationand expressing
emotions
Sensitive to other’s opinions about
themselves
6-9 yr: have questions about
pregnancy, intercourse, sexual
wearing, look for nude pictures in
books, magazines
10-12 yr: games with peeing, sexual
activity (e.g., strip poker, truth/dare,
boy-girl relationships, flirting, some
kissing, stroking/rubbing, reenacting
intercourse with clothes on)
Possible effects of maltreatment
Poor social/academic adjustment in school: preoccupied, easily
frustrated, emotional outbursts, difficulty concentrating, can be overly
reliant on teachers; academic challenges are threatening, cause anxiety
Little impulse control, immediate gratification, inadequate coping skills,
anxiety, easily frustrated, may feel out of control
Extremes of emotions, emotional numbing; older children may “self-
medicate” to avoid negative emotions
Act out frustration, anger, anxiety with hitting, fighting, lying, stealing,
breaking objects, verbal outbursts, swearing
Extreme reaction to perceived danger (i.e.,“fight, flight, freeze”
response)
May be mistrustful of adults, or overly solicitous,manipulative
May speak in unrealistically glowing terms about his parents
Difficulties in peer relationships; feel inadequate around peers; over-
controlling
Unable to initiate, participate in, or complete activities, give up quickly
Attachment problems: may not be able to trust, tests commitment of
foster and adoptive parent with negative behaviors
Role reversal to please parents, and take care of parent and younger
siblings
Emotional disturbances: depression, anxiety, post traumatic stress
disorder, attachment problems, conduct disorders
 Adolescents
Physical Cognitive
Growth spurt: Formal operations: precursors in early
Girls: 11-14 yrs adolescence, more developed in middle and
Boys: 13-17 yrs late adolescence, as follows:
Puberty: Think hypothetically: calculate
Girls: 11-14 yrs consequences of thoughts and actions
Boys: 12-15 yrs without experiencing them; consider a
Youth acclimate to changes number of possibilities and plan behavior
in body accordingly
Think logically: identify and reject
hypotheses or possible outcomes based on
logic
Think hypothetically, abstractly, logically
Think about thought: leads to introspection
and selfanalysis
Insight, perspective taking: understand and
consider others’ perspectives, and
perspectives of social systems
Systematic problem solving: can attack a
problem, consider multiple solutions, plan a
course of action
Cognitive development is uneven, and
impacted by emotionality
Social
Young (12 – 14):
Psychologically distance self from
parents;identify
with peer group; social status
largely related to group
membership; social acceptance
depends on conformity to
observable traits or roles; need to
be independent from all adults;
ambivalent about
sexual relationships, sexual
behavior is exploratory
Middle (15 – 17):
friendships based
on loyalty, understanding, trust;
self-revelationis first step towards
intimacy; conscious choices about
adults to trust; respect honesty &
straight for wardness from adults;
may become sexually active
Morality: golden rule;
conformity with law is necessary for
good of society
 Adolescents (cont’)
Emotional
Psycho-social task is identity formation
Young adolescents (12-14): selfconscious about
physical appearance and early or late
development; body image rarely objective,
negatively affected by physical and sexual abuse;
emotionally labile; may over-react to parental
questions or criticisms; engage in activities for
intense
emotional experience; risky
behavior; blatant rejections of
parental standards; rely on peer
group for support
Middle adolescents (15-17):
examination of others’ values,
beliefs; forms identity by organizing perceptions
of ones attitudes, behaviors, values into coherent
“whole”; identity includes positive self image
comprised of cognitive and affective components
Additional struggles with identity
formation include minority or biracial status,
being an adopted
child, gay/lesbian identity
Possible effects of maltreatment
All of the problems listed in school age
section
Identity confusion: inability to trust in self to be a healthy
adult; expect to fail; may appear immobilized and without
Direction
Poor self esteem: pervasive feelings of guilt, self-criticism,
overly rigid expectations for self, inadequacy
May overcompensate for negative selfesteem by being
narcissistic,
unrealistically self-complimentary;
grandiose expectations for self
May engage in self-defeating, testing, and aggressive,
antisocial, or impulsive
behavior; may withdraw
Lack capacity to manage intense
emotions; may be excessively labile, with frequent and
violent mood swings
May be unable to form or maintain
satisfactory relationships with peers
Emotional disturbances: depression,
anxiety, post traumatic stress disorder,
attachment problems, conduct disorders
 Adulthood

Educational History
– She entered elementary school when she was 7 years old but she
didn’t passed it.
– There is no valid data about patient school history, her
achievement, relationship with teachers, favourite studies.
There is also no valid data about patient’s participation in sport
and hobbier, her attitude at school, how many her friends, social
popularity, participation in group activities.
 Adulthood (cont’)
 Social Activity  Current Situation
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.
 Religion History
She is a moslem. She believes her
God. But since she was ill, she
rarely prays on five times
 Criminal History
No criminal history
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.
 Erikson’s Stages of Psychosocial Development

Stage Basic Conflict Important Events

Infancy (birth to 18 Trust vs mistrust Feeding
months)
Early childhood (2-3 years) Autonomy vs shame and Toilet training
doubt
Preschool (3-5 years) Initiative vs guilt Exploration
School age (6-11 years) Industry vs inferiority School
Adolescence (12-18 years) Identity vs role Social relationships
confusion
Young Adulthood (19-40 Intimacy vs isolation Relationship
years)
Middle adulthood (40-65 Generativity vs Work and parenthood
years) stagnation
Maturity(65- death) Ego integrity vs despair Reflection on life
Conclusion: no clear data
GENOGRAM
Symptom

2010 2011 2012 2013 2014 2015

Role of Function
Mental State (December, 9th 2015)
o Appearance
o A female, appropriate to his age, wear complete
clothes, enough self grooming.

o State of Consciousness
o Clear

o Connection of psychic
o Attention easily attracted, unable to sustained
concentration (+)
 BEHAVIOUR

Mannerism
Hypoactive Psychomotor
Automatism agitation
Hyperactive
Bizarre Compulsive
Echopraxia
Command Ataxia
Catatonia
automatism
Active negativism Mimicry
Mutism
Cataplexy Aggresive
Acathysia
Stereotypy Impulsive
Tic
Abulia
Somnabulism
 ATTITUDE

Non-cooperative
Infantile Passive negativism
Indiferrent
Distrust Catalepsy
Apathy
Labile Cerea flexibility
Tension
Rigid Excitement
Dependent
 Emotion

Mood Affect

• Dysphoric • Appropriate
• Elevated • Inappropriate
• Euphoria • Restrictive
• Expansive • Blunted
• Irritable • Flat
• eutimic • Labile
 Disturbance of Perception

Hallucination Illusion

• Auditory •Auditory
• Visual •Visual
• Olfactory •Olfactory
• Tactil •Tactil

Depersonalisation - Derealisation -
 Thought Progression
Quantity Quality
• Irrelevan answer
• Logorrhea • Incoherence
• Blocking • Flight of idea
• Remming • Confabulation
• Mutisme • Poverty of speech
• Talkative • Slow speech
• Loosening of association
• Neologisme
• Circumtansiality
• Tangential
• Verbigrasi
• Perseverasi
• Sound association
• Word salad
• Echolalia
 Content of thought
 Idea of Reference
 Preocupation
 Obsession
 Phobia
 Delusion of Persecution
 Delusion of Reference
 Delusion of Envious
 Delusion of Hipochondry
 Delusion of magic-mystic
 Fantasy
 Delusion of Grandiose
 Delusion of Control
 Delusion of Influence
 Delusion of Passivity
 Delusion of Perception
 Thought of Echo
 Thought Insertion
 Thought of withdrawal
 Thought Broadcasting
Form of Thought

• Realistic

• Non Realistic

• Dereistic

• Autistic
 Sensorium and Cognition

 Orientation of time/
place/people/situation : Good/Good/Good/Good
 Level of education : less
 General knowledge : less
 Working/short/long memory : less
 Writing and reading skills : Moderate
 Ability to self care : Good
Impulse Control When Examined
• Self control : Good
• Patient response to examiners question: Good

Insight
• True Insight
 Physical Examination

 Conciousness : compos mentis

 Vital sign:
- Blood pressure : 120/70 mmHg
- Pulse rate : 120 x/min
- RR : 20 x/min
- Temperature : 36,5o C
 Review System

a. Head :
 normocephali, mouth deviation (-)
 anemic conjungtiva (-), icteric sclera (-), pupil isocore
b. Neck : normal, no rigidity, no palpable lymph nodes
c. Thorax :
 Cor : S1 S2 regular, murmur -, gallop -
 Lung : vesicular sound +/+, wheezing -/-, ronchi-/-
d. Abdomen :
 Flat, abdominal wall//chest wall, normal peristaltic,
tympany sound, tenderness -, mass -, liver, spleen and
kidney not papable
e. Extremity : Warm acral, capp refill <2”, edema (-)
 Neurogical Examination
 Physiological reflex (Not asessed)
o Upper extremities: biceps reflex , triceps reflex ,
brachioradial
o Lower extremities: patella reflex , achilles tendon
reflex

 Pathological reflex (Not asessed)

o Upper extremities: Hoffman , Tromner
o Lower extremities: babinski,
chaddok,gordon,oppenheim, rossolimo

 Motoric examination
o Normal movement, good coordination, normal
strength
 Neurogical Examination (cont’)

 Meningeal sign : Not asessed

 Physiologic reflex : Not asessed

 Patologic reflex : Not asessed

NEUROGICAL EXAMINATION (CONT’)
Cranial nerves examination:
 CN I : Not asessed
 CN II : Not asessed
 CN III,IV,VI : Not asessed
 CN V : Not asessed
 CN VII : Not asessed
 CN VIII : Not asessed
 CN IX : Not asessed
 CN X : Not asessed
 CN XI : Not asessed
 CN XII : Not asessed
 SIGNIFICANT FINDING RESUME
Onset : 15 month ago. The patient was brought to RSJS Magelang by her
family on December 7th, 2015 because she often felt her heart pounded

Symptoms Mental status Impairment

• The fight was played in • Mood: disphoric • Resign from her job
her mind repeatedly • Form of thought: • Restricted social
• She avoided to see a Autistic interaction
fight
• She was very sad and
desperate
• She got lost of Vital sign
pleasure.
• She got lost her energy Pulse rate : 120 x/min
• She had no appetite to
eat
• She couldn’t sleep
well.
• She often felt dizzy
• She more often worried
 SYNDROME
 Depressed mood
 Lost of pleasure
 Reduce energy, lackness Syndrome of depression
 sleep disturbance
 Decrease in appetite
 Diminished to think or concentrate

• Worried
 Autonomic overactivity (dizzy, pounding Syndrome of anxiety

heart)

•Severe traumatic event

•Flashback of that traumatic event repeatedly
Syndrome of PTSD
•Automatic disorder, affectif disorder
 DIFFERENTIAL DIAGNOSIS

F32.2 Severe Depressive Episode without

psychotic symptoms
F41.1 Generalized Anxiety Disorder
F41.2 Mixed Anxiety and Depression
F43.1 Post-Traumatic Stress Disorder
 MULTIAXIAL DIAGNOSE

 AXIS I : F43.1 Post-Traumatic Stress Disorder

 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 60-51, GAF current 70-61
PROBLEM RELATED TO THE PATIENT
Problem about patient’s biological state (biology)
There were abnormality imbalance neurotransmitter, serotonin,
dopamine, GABA, and norepinephrine.

Problem about patient’s mental state (psychology)

 The patient often felt worried
 The patient had poor appetite and couldn’t sleep well
 She avoided to see a fight
 She was very sad and desperate
 She had no appetite to eat
 She couldn’t sleep well.
 She often felt dizzy
 She got lost of pleasure.
 She got lost her energy
PROBLEM RELATED TO THE PATIENT
(Cont’)
Problem about patient’s life (social)
• The patient was a closed person before he sick.
• The patient never told any of his problems to his family or
friends
• She lives alone
 PLANNING MANAGEMENT

INPATIENT (HOSPITALIZATION)
 No indication

Response Remission Recovery

PLANNING MANAGEMENT (Cont’)
 RESPONSE PHASE
Target therapy :
50% decrease of symptoms

Maintenance
 Fluoxetine 1 x 20 mg
Reason: we choose antidepressant drugs for this patient because this
patient have some depression sydrome and PTSD syndrome,
antidepressant drugs most effective against thats syndrome . The other
reasons are because 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
 Clobazam 2 x 10 mg
Reason: we choose antianxiety drugs for this patient because this
patient have some anxiety sydrome and antianxiety drugs most effective
against thats syndrome. The other reasons are because Benzodiazepine
as anti-anxiety have a high therapeutic ratio, less addiction with low
toxicity. Clobazam didn’t affected psychomotor performance.
 REASON
 Fluoxetine
o Easy to get it
o Cheap
o Minimal side effect
o Available within BPJS catalog
o Suitable for geriatri patient and other type
antidepressant
o Increase patient complience (one daily dosing)
and a wide therapeutic index

 Clobazam
o Easy to get it
o Suitable for active geriatri patient cause it has
less effect psychomotor performance
o Available at the hospital
 PSYCHOTHERAPY

CBT
 Cognitive behavioral therapy (CBT) is one type of
counseling. Research shows it is the most effective
type of counseling for PTSD.
 Goal:

o To help a person learn to recognize negative

patterns of thought, evaluate their validity, and
replace them with healthier way of thinking
o To help patient change patterns of behavior that
come from dysfunctional thinking
 FAMILY EDUCATION

 Tell to her family about her problem and

her mental disorder and how to treat it;
 Provide guidance to the family to keep
active role in every patient management
process;
 Briefed the families about the importance
of the drug to the patient's recovery so
families need to remind and monitor the
patient to take medication irregularly.
DOCUMENTATION
Thank you