Skizofrenia Herbefrenik

8/10/2019 Skizofrenia Herbefrenik

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Skizofrenia Herbefren

Heri Fitrianto P. 1483

Muhammad Iqbal P. 1489


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CASE REPORT

A 31 years old female patient, came to the Mental PolyclinicM.Djamil Hospital Padang on October 27, 2014 at 01:00 pmescorted by her mother. The Patient tried to kill herself by ubefore coming to the hospital. This is the first attack, hospitfor the three times too. The symptoms felt now is more sevethe previous one.


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Patient identity:

Name / Age : Mrs. SW / 31 years old

MR : 00.38.41.XX

Gender : Female

Place and date of birth : Padang, June 28th 1983

Marital status : Married

Religion : Muslim

Occupation / School : non-employed / not graduated from Elementary S5thgrade )

Citizen : Indonesian

Tribe : Minangkabau

Address : Komplek Tarok I J/18, Kecamatan Kuranji Kota Padang


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Internal Status General appearance : Composmentis

Blood pressure : 120/80 mmHg

Pulse : palpable, regular, 82 times per minute,

Respiration : toracoabdominal, regular, 18 times per m

Temperature : 36,70C Body Shape : normal

Height : 158 cm

Weight : 47 kg


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Respiratory system : Inspection : Symmetrical on both left and right site in

and dynamic state

Palpation : Fremitus left side equal to the right

Percussion : Sonor throughout the lung fields

Auscultation : Vesicular breath sounds, no ronkhi, wheezing


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Cardiovascular system : Inspection : Ictus is not visible

Palpation : Ictus was palpable 1 finger onmedial side of LMCS RIC V

Percussion : Cardiac border was obtained norma

Auscultation : Pure heart sounds, regular rhfrequency 82x / min, no cardiac murmur


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Gastrointestinal system : Inspection : no bulge

Palpation : Liver and spleen were not pal

Percussion : tympanic

Auscultation : normal intestinal murmurs

specific abnormalities : not found


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NEUROLOGICAL STATUS

Central nervous System (sensory) : sight, smell, hearing, taste, and touch were fine

Symptoms of brain meningean stimulation : stiff neck negative

Symptoms of increase intracranial pressure : projectile vomitting negative, prheadache negative

Eyes

Movement : can be moved in any direction, nistagmus negative

Perception : diplopia negative Pupil : round, isochors,

Lights reflex : positive / positive

Convergence reflex : was not performed

Cornea reflex : was not performed

Ophthalmology : was not performed


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Motoric Tone : Eutone

Turgor : good

Strength : 555 555

555 555

Coordination : Good Reflex :

Physiologic (patella) : ++/++

Pathologic : Babinsky reflex negative


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Sensibility : smooth and rough were good

Vegetative neuron : eating, sleeping, and waking function were

Supreme functions : Activity of reading, and languange caperformed well, writing,, drawing,, and numeracy cannot be pewell

Spesific disorder

stiffness : none

tremor : none

nasal stiffness : none

occulogiric crisis : none

torticolis : none


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Laboratory Test 28 Oktober2014

HB = 14,3 g/dl

Ht = 44,4%

Platelet = 264.000 /mm3

Leukocytes = 7.400 / mm3


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ALLOANAMNESIS

Name / Age : Mrs. S/ years old Jenis Gender : Female

Address/phone : Komplek Tarok I J/18, Kecamatan Kuranji Padang

Occupation : Noodle Sellers

Education : Ungraduated form elementary school

Relationship with the patient : Patient's mother


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Main reason for hospitalization

Patients tried to suicide with knife.

Current Chief Complain: Patient have thougt theres no reason for heranymore

Past History of illness

2002

Patient was irritable suddently, threated others, and ruined everythinhouse. Ever since patient often was brougt to the hospital by her famihospitalized at Dr. M. Djamil Padang Hospital and HB. Saanin Hospital.tried to kill herself by drinking baygon several times. Patient also hit hthe wall and throw her self to the car.


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Her mother often brought her to the hospital if her symptomrelapsed. Sometimes patient regularly took medicine but sonot. Patient got iritated when someone remembering her tomedicine.

2012

Patient got married with her mother friends son and her hudumped her away. They didnt contact each other anymorepatient wanted to find her husband but she hadnt enough


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2013 She stole her cousin dress and brought to her sister house. S

busted by her cousin and her cousin sended her to Dr. M. DjHospital again.

2014

Patient tried to suicide again by using knife after she got insby demon but she had busted by her mother and then her mbrought her back to Dr. M. Djamil Hospital


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Premorbid History Infant : born spontaneously, aterm, attended by midwiv

history of cyanosis, jaundice, or seizure.

Childhood : Growth and development were appropriate wit

Teenage : Growth and development were appropriate wit

teenagers on his age, but she had goofy face and irritable.


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III. Educational Background

Elementary school : ungraduated in third year because hehad insufficient fund.

IV. Occupation History

Patient never had occupation.

V. Marital Status

Married VI. Socio-economic history

Patient was living with her mother and her brother. The house ispermanent one, there is electricity, the source of water is from wPatient hadnt vehicle.


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VII.Family History


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VII. Graphic of illness

2002 2013 2014


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AUTOANAMNESISQuestions Answers Interpretat

Assalamualaikum, perkenalkan

buk kami dokter muda di siko.Namo awak Heri, ko kawan awak

Iqbal. Sia namo ibuk?

Ayu, Sri Wahyuni.

Kooperatif, orien

terganggu, orient

tidak terganggu,personal tidak te

Buliah awak mananyo nanyo ibuk

sabanta?

Buliah

Bara umua ibuk? Bilo ibuk lahia?

Hari apo kini buk?Tanggal bara kini buk?

Limo hari lai hari apo buk?

Ibuk tau dima kini?

31 tahun, tanggal 27 Juni 1983

Hari Rabu

Tanggal 29 Oktober 2014

Hari minggu

Lai, di bangsal Jiwa M.Djamil

Sia yang maantaan ibuk ka siko? Jo amak ambo ka siko.


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A nan ibo kini raso?

A nan sakik jo ibuk?

Indak Ado do

Ambo ndak meraso sakik

Discrimina

terga

Lah ka bara kali ibuk dibaok

kasiko?

Baa ko ibuk dibaok ka siko?

3 kali

Nio barubek kulit yang gata gata

Tahun bara pertamo kali

kasiko?

Dek a tu kasiko dulu buk?

2009

Ndak manga manga do

Nan kaduo bilo kasiko buk? Dek mambaok baju si neli ka rumah

Meri. Jadi, inyo berang, tu ambo

dimasukaan ka siko.


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Kecek amak ibu, ibuk nio bunuh diri.

Dek a tu?

Waktu tu, apo kecek setan tu?

Waktu tu, nampak ndak setannyo?

Waktu tu, ado nan ta baun ndakbuk?

Waktu tu, ado nan taraso?

Ambo disuruh setan.

Ndak ado guno iduik, mati se lah lai.

Hitam setannyo

Ado, bau angik (busuk)

Ado, tangan ibu di rese jo setan.

Halusinasi visua

olfakto

Ibuk ka dapek pitih saratui ribu di

jalan, ka ibuk pangaan pitih tuh?

Bali cindua

Discriminative Jud


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Ibuk ado maraso punyo

kekuatan ndak?bisa maubekan

urang?maraso urang hebat?

Sejak di siko ado taraso berang

jo amak yang baok ibuk ka siko?

Ado indak ibuk curiga jo

kaluarga ibuk?

Ndak do

Ndak do

Dendam

Curiga

Kalau lalok baa buk?lai lamak? Lai bisa. Tidu

Alah makan tadi buk? Alah. Maka

Ibuk, kalau pulang dari siko ka

nio manga rencana?

Ambo nio cuci piriang, mamasak buek

abang

Hubungan re

(sudah berpis

sejak ta


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II. Specific condition

Affective Affective condition : Dull Emotional :

a. Stability : labil

b. Control : fair

c. Echt/Unecht : Echt

d. Einfuhlung : inadequate e. Deep/shallow : shallow

f. Differentiation scale : narrow

g. Emotional flow : slow


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Intelectual function and condition

a. Memorization ability : poor

b. Concentration : decrease

c. Orientation : disturbed in terms of timplace

d. knowledge : hard to asses

e. Discriminative insight : disturbed

f. Intelligence prediction : below average

g. Discriminative judgement : disturbed

h. Intelectual decreasing : none


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Sensation and perception abnormalities

a. illusion : none

b. hallucination

- accoustic : present

- visual : present

- olfatoric : present

- tactile : present


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Thought process condition

Speed of thought process : Slow

quality of thought :

clear and sharp : disturbed

incoherent : present

Sperrung : none

Hemmung : none Flight of ideas : none

verbigeration : none

preservation : none


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Instingtual drive and behaviour abnormalities

abulia : none

stupor : none

raptus/impulsivity : none

excitement state : none

sexual deviation : none


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echopraxia : none

vagabondage : none

pyromani : none

mannerism : none

others : none

Overt anxiety : none

Reality testing ability : disturb in behaviour, thinking


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MULTIPLE AXIS RESUME

Axis 1. Clinical Syndrome

The Patient tried to kill herself by using knife before cominghospital. This is the first attack, hospitalization for the three The symptoms felt now is more severe than the previous on

General appearance: composmentis cooperative, sensorial iAttention is good, initiative is less, motoric active, facial exppoor, verbalization influent, psychic contact could be done, and long.


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Specific condition

Affective condition : dull, labil, less, echt, inadequate, shalloslow.

Intelectual condition and function: memorization ability pooconcentrate, orientation is disturbed in terms of time and pknowledge is hard to asses, discriminative insight disturbed,intelligence prediction is hard to asses, discriminative judgedisturbed.


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Sensation and perception abnormalities: no illusion, acousti

olphactoric, visual and tactile hallucinations are present

Thought process condition : Slow, incoherent, and little.

Reality testing ability : disturbed in behaviour, thinking and f


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Axis II.Personality Disorder and mental retardation disorder

Personality : has no friends, obedient to her parents Mental retardation : none

Axis III. General medical condition

There's no history of malaria, typhoid, capitis trauma, and other diseaneed to be hospitalized

Axis IV.Phsycosocial and environtment stressor

Break the relationship with her husband Axis V.Global assesment of function

No social relation activity. free time activity (watching TV, reading, recreation) could not be done well part

spend her time at home, no interest to have outdoor activity Daily activity (bathing, washing, working) could not be implemented partially.


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Multiple Axis Diagnose

F 20.1 Skizofrenia herbefrenik

No Diagnose

No Diagnose

No Diagnose

GAF 41-50


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Therapy F20.3 Undifferentiated Skizofrenia

F25.1 Schizoaffective disorder Depressive type

F20.8 Others Skizofrenia

Therapy

Risperidon 2 x I @ 2 mg Haloperidol 2 x I @ 1,5 mg

Vitamin B kompleks 3 x I @ 50 mg

Vitamin C 3 x I @ 50 mg


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PROGNOSEPenilaian Good Bad

Onset Teens

Relaps Exist

Diagnose F20. 1 Skizofrenia

Herbefrenik

Family support Present

Medical Response Bad

State of Economy Bad

Medication adherence Not obedient

Precipitating factors Clear

Family History Abstance

Other Disease / Other

Disorder

Abstence


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Clinical : dubia et malam

Functional : dubia et malam

Social : dubia et malam


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Thank You

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Skizofrenia Herbefrenik