Case Report Session

SKIZOFRENIA PARANOID

Oleh :

Ryan Farried Ramadhan P.1029 Leonard Khriestsandi Saleh P.1031

Pembimbing :

dr. Yaslinda Yaunin Sp.KJ

BAGIAN ILMU KEDOKTERAN JIWA FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS RUMAH SAKIT PROF. DR. HB SAANIN PADANG 2012 1

Case Report
A woman came to polyclinic Prof. HB Saanin Mental Hospital on October 12th 2012 by her family with symptoms : abstracteding, got angry to people around her, talk and laugh to herself since a month. Sick for the third time, and never hospitalized before. Patient Identity: Name MR Sex Date of birth / Age Marital Status Occupation/Education Address Hometown Religion Nationality Race A. Internal Satus General Condition Blood Pressure Pulse rate Respiratory rate Temperature Height Weight Respiratory System Cardiovascular Sytem Digestive System Genital System Spesific Disorder : moderate : 120/70 mmHg : 84x per minute, regular : 21x per minute, reguler : 36,80C : 155 cm : 50kg : in normal range : in normal range : in normal range : was not performed : was not found : Mrs. M : 004823 : Female : November 6st 1955 / 57 Years Old : married : Unemployed : Villa anggrek E19 air dingin : Sijunjung : Islam : Indonesia : Minangkabau

B. Neurological Status 1. Central Nervous System Symptoms of brain meningean stimulation : stiff neck negative Symptoms of increase intracranial pressure : projectile vomitting negative, progressive headache negative Eyes Movement negative Perception Pupil Lights reflex Convergence reflex Cornea reflex Ophthalmology Motoric Tone Turgor Strength Coordination Reflex Sensibility Vegetative neuron Supreme functions language done Spesific disorder stiffness tremor nasal stiffness occulogiric crisis : none : none : none : none 3 : normal : good : 555/555 555/555 : Good : Physiologic (patella) : positive/positive Pathologic (babinsky) : negative/negative : smooth and rough are good : eating, sleep, and wake normal : reading, writing, drawing, memory, and well : diplopia negative : round, isochors, : positive / positive : positive / positive : was not performed : was not performed : can be moved in any direction, nistagmus

 torticolis

: none

ALLOANAMNESA
Name Address/ phone. Occupation Education : Mr S. : Villa anggrek E19 air dingin / 081374101xxx : employee : SMK

Relationship with the patient : Brother 1. Main reason for hospitalization abstracteding, got angry to people around her, talk and laugh to herself since a month. Sick for the second time, and never been hospitalized before 2. Current Chief Complain: no complain 3. Past History of illness 2011. She was talking by herself and often inconsequential, walking around and abstracteding. Two weeks before the symptomps her daughter died due to car accident, her daughter was 25 years old. She was really shock with her daughter death. She was brought to health center and got medicine, but she didn't take the medicine regularly. 2012. She was talking by herself, got angry to people around her. Her family brought her to polyclinic HB Saanin mental hospital. Premorbid History Infant seizure. Childhood Teenage : Growth and development appropriate with age : pray five times a day, has many friends : born spontaneously, no history of cyanosis, jaundice, or

4. Educational Background - Elementary school : SDN Sijunjung, graduated in 6 years - Junio high school : SMPN Sijunjung, graduated in 3 years -SMK : SMKN Sijunjung, graduated in 3 years 5. Marital Status: Married. 6. Occupation : she doesnt work

7. Social and economic background live in her house with her family in a permanent house, electricity and water from PDAM. She has one motorcycle. Her needs are fulfilled by her husban. 8. Family History

Her grandmother from her mother have mental disorders. 9. Graphic of illness her daughter's death didnt take medication regularly

2011 AUTOANAMNESIS (November 12nd 2012) Pertanyaan - Sore buk, awak tanyo-tanyo stek yo? - Sia namonyo buk? - Bara umur buk? - dima ibuk tingga? - ado ibu mandangadanga suaro-suaro? Jawaban - Yo pak - Namo awak "M" - 57 tahun - di sijunjuang - iyo ado, anak wak ngecek ka awak, nyo manangih-nangih tadanga dek awak

2012

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Interpretasi - Kooperatif

halusinasi akustik (+)

- Ado mengecek ka ibu?caritoalah buk.. - Ado ibuk manampak anak ibuk waktu tu? caritoanlah buk.. - ada ibuk manciumcium bau harum atau busuak waktu? - ado waktu tu ibu raso dipacik samo anak ibuk? - ado ibu maraso bisa dibaco pikiran ibuk - ado ibuk bisa mambaco pikiran urang bu? - ado ibuk ndak ibu mandanga ado yang manyuruah-nyuruah ibuk? - apo keceknyo bu? caritoanlah buk - ado ndak pengalaman ibuk yang aneh yang lain yang ibuk alami? - kalau ibu bajalan di muko urang, ado ndak maraso ibuk dipakecean urang tu? - ado ibu raso dandam jo urang?atau bamusuahan se

- indak, nyo manangih senyo. - iyo ado, nyo pakai baju putih, puceknyo bantuaknyo. - indak ado tabaun apo-apo do.

halusinasi visual (+)

halusinasi olfaktorik (-) halusinasi taktil (-)

- Ndak ado

ndak ado

- Ndak ado

- iyo, Ado - disuruahnyo wak manabrakan diri ka oto, tapi ndak do wak lakuan do. ndak amuah wak do. - indak ado - iyo ado, dikecekannyo wak, dikecekannyo anak wak maningga garagara awak. ibo hati wak jadinyo - indak ado -

delution of control(+)

curiga (+)

mancaliak urang - ado ndak ibuk maraso randah diri? - kalau maraso jadi urang gadang ado buk? - ibu kini tau baa mako ibu disiko? - ibu dirumah biasonyo manga se buk sehari-harinyo - kalo pulang apo rencananya ibu?

- indak - indak - kecek urang awak gilo, awak ndak do gilo do. - dirumah senyo, masak, nyuci, barasiahan rumah - yo dirumah senyo, karajo seperti biaso

waham (-)

Discriminative insight terganggu

SUMMARY OF PSYCHIATRYCH ( November 12th, 2012 ) 1. General Appearance Conciousness/ sensorial Attitude Motoric Facial expression Verbalization Physic contact Attention Initiative 2. Specific condition A. Affective 1. 2. Affective condition Emotional : a. Stability b. Control c. Echt/Unecht d. Einfuhlung e. Deep/shallow f. Differentiation scale : labil : less : Echt : inadequate : shallow : narrow 7 : inapropriate : composmentis / good : cooperative : active : rich : can speak, quite fluent : could be done/quite appropriate/quite long : present : present

g. Emotional flow B. Intelectual function and condition a. Memorization ability b. Concentration c. Orientation d. knowledge e. Discriminative insight f. Intelligence prediction g. Discriminative judgement h. Intelectual decreasing C. Sensation and perception abnormalities a. illusion b. hallucination - accoustic - visual - olfatoric - gustatoric - tactile D. Thought process condition 1. Speed of thought process: fast 2. quality of thought : a) clear and sharp b) incoherent c) Sperrung d) Hemmung e) Flight of ideas f) verbigeration g) preservation 3. Thought condition a) Central pattern b) phobia : none : none

: fast

: good : decrease : good : hard to asses : disturbed : normal average : disturbed : none : none : present : present

Since 4 weeks ago, it still presents. : none : none : none

: clear less and sharp less : none : none : none : none : none : none

c) obsession d) delusion e) suspicion f) confabulation g) repultion h) inferior feeling i) Much/little j) feeling guilty k) hypochondria l) others a) abulia b) stupor d) excitement state f) echopraxia g) vagabondage h) pyromani i) mannerism a) others F. Over anxiety G. Reality testing ability feeling RESUME MULTIPLE AXIS Axis I. Clinical Syndrome

: none : present, delusion of control : present : none : none : none : much : none : none : none : none : none : none : none : present : none : none : none : present, much : disturb in behaviour, thinking and

E. Instingtual drive and behaviour abnormalities

c) raptus/impulsivity : none e) sexual deviation : none

abstracteding, got angry to people around her, talk and laugh to herself since a month. Sick for the third time, and never been hospitalized before General appearance : compos mentis/ good, cooperative, active, rich, can speak, fluent enough, could be done/quite appropriate/ quite long, attention present, initiative present. Specific condition : 9

a. Affective condition : inapropriate, labil, less, echt, inadequate, shallow, narrow, fast. b. intelectual condition and function : memorization ability good, hard to concentrate, orientation good, knowledge is hard to asses, discriminative insight disturbed, discriminative judgement disturbed. c. Sensation and perception abnormalities: no illusion, acoustic and visual hallucinations are present d. Thought process condition : fast, clear less and sharp less e. Instinctual drive and behaviour abnormalities : vagabondage present f. over anxiety : present, much g reality testing ability : disturbed in behaviour, thinking and feeling Axis II. Personality Disorder and mental retardation disorder Personality : has many friends, pray five times a day mental retardation : none Axis III. General medical condition There's no history of malaria, typhoid, trauma capitis, and other disease that need to be hospitalized Axis IV. Phsycosocial stressor and environtment Her daughters death Didnt take the medication regularly her grandmother has mental disorder Axis V. Global assesment of function social relation free time activity Daily activity Multiple Axis Diagnosis I. II. III. IV. F.20.0 Paranoid Schizophrenia no diagnosis no diagnosis didnt take medication regularly 10 : social activity could not be done since 4 weeks ago : mostly spend her time at home, no interest to have : eating, bathing as before

outdoor activity since 4 weeks ago

V.

GAF 51-60

Differential Diagnosis F 20.8 Others Schizophrenia F 20.9 Unclasified Schizophrenia F 25.1 depresif type Schizoafective Therapy Chlorpromazine 1xI tab @ 100 mg Haloperidol 3xI tab @ 1,5 mg Trihexyphenidil 2xI tab @ 2 mg

ANJURAN TERAPI Farmakoterapi o Chlorpromazine 1xI tab @ 100 mg o Haloperidol 3xI tab @ 1,5 mg o Trihexyphenidil 2xI tab @ 2 mg o Diazepam 1xI tab @ 2 mg PROGNOSIS clinic Functional Social : dubia et bonam : dubia et bonam : dubia et bonam

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