skizofrenia herbefrenik
TRANSCRIPT
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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