MINI CEX

Mental Organic
Disorder

Oleh :
Mirantika Audina I4061172033

Pembimbing:
dr. Sabar Parluhutan Siregar, Sp.KJ

FAKULTAS KEDOKTERAN
UNIVERSITAS TANJUNGPURA
2018
IDENTITY

Patient’s Identity Relative Identity

• Name : Mrs. S • Name : Mrs. T
• Age : 58 years old • Age : 40 years old
• Gender : Female • Gender : Female
• Address : Baten Candimulyo • Address : Baten Candimulyo
• Religion : Moeslem • Occupational : Marchandise
• Ethnic : Java • Relation : Biological daughter
• Marital Status : Married • Intimacy : Close
• Occupational : -
• Education : Elementary School
• Date of Entry : October 15th,
2018
• Date of examination :
October 15th, 2018
ANAMNESIS

The reason why patient was bring to the hospital

Patient bring to hospital because patient like to walk inside the

house and doesnt sleep
ANAMNESIS
Present story of patient illness :

From alloanamnesis with her daughter found that patient

was bring to mentol hospital Prof. dr. Soerojo Magelang
because the patient like to walk inside their home and had
dificulties in sleeping. She also had a change in her
behavior such as easily to get annoyrd, do something in
repeatation and forgot her current activity before. The first
time a significant behavior happen when patient took care
of her husband’illnessalone by herself. After that she
become easily got annoyed and easily to forget things.
When she watched a movie, she didnt know the channels
about. She had poor sleep and for her daily living she need
helped by her daughter, patient’s communication with her
neighbour or friend also decreased.
ANAMNESIS
History of Illness :
• Psychiatric disorder :
There is no history of patients’s psychiatric illness
• General medical illness disorder :
there was a history of hypertension in her family
• 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 study untul elementary school
- Occupational : housewife
- Marital staus : married
- Criminal : patinet has no criminal history
- Social activity : there was no valid data
- Psycosocial : Patient have a normal relationship with her
family buat lately sle seldom talked with her family or
neighbour
- Current situaton : Patient lived with her children and for
her daily living need helped by her daughter

Family History :
There is no history of same symptoms in his family
PEMERIKSAAN FISIK
Status Internus
KU : Baik TD : 160/89 mmHg RR : 22 x/menit
Kesan : Compos mentis HR : 98 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, 58 years old, appropriate to her age, good for self care,
were complete and clean clothes
Orientation (P/T/P/S) : Good
Psycis contact : Present, euitable, constant.
Behavior : Normoactive
Verbal :
- Quantity : normal
- Quality : normal
Mood : Eutymic
Affect : Normal, appropriate
Perception :
- Hallucination (-)
- Illusion (-)
- Depersonalization (-)
- Derealization (-)
MENTAL STATUS EXAMINATION
Thouhgt of Process :
- Quality : Coheren
- Quantity : Remming
Thouht of Content :
Normal
Thought Form :
realistic
Insight : True insight
Attention Connection :
Attention enough, unable to sustained concentration
MENTAL STATUS EXAMINATION
Sensorium and Cognitive :
- Level of education : can’t be assess
- General knowledge : can’t be assess
- Orientation : bad
- Woring/Short/Long memory : bad
- Ability to read and write : low
- Ability to independent : bad
Impulsive control when examine :
- Self control : bad
- Patient respons : bad
DIAGNOSIS
Organic syndrome :
- Deficit Memories
- Deficit cognitive
- Deficit sensorium

DIAGNOSIS BANDING
F00.00 Dementia on Earyl Onset Alzheimer
F01 Dementia Vascular
F02.8 Dementia causesby other disease
DIAGNOSIS MULTIAKSIAL
AKSIS I : F00.00 Dementia on Earyl Onset Alzheimer
AKSIS II : No Diagnosis
AKSIS III : Circulatory Disease
AKSIS IV : Unclear stressor
AKSIS V : 40 – 31 currently
MANAGEMENT PLANNING
Patient doesn’t need to hospitalized
Maintenance therapy :
Ability 2 mg + THP >> cap 0-1-8
Clobazam 10 mg 1x1 PO
Domenprezil 5 mg 1x1 PO
Meropan 0,5 mg 1X1 po

Psycotheray :
- Behavior management
- The patient need family support
- Explain that environment, neightborhood, family situation
assocaited to the disorder.
PROGNOSIS
Quo ad vitam : malam
Quo ad functionam : Dubia ad malam
Quo of sanactionam : Dubia ad malam
THANK YOU