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 JIWAFAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS

RUMAH SAKIT PROF. DR. HB SAANINPADANG

2012

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Case ReportA woman came to polyclinic Prof. HB Saanin Mental Hospital on October 12 th 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 : Mrs. M

MR : 004823

Sex : Female

Date of birth / Age : November 6st 1955 / 57 Years Old

Marital Status : married

Occupation/Education : Unemployed

Address : Villa anggrek E19 air dingin

Hometown : Sijunjung

Religion : Islam

Nationality : Indonesia

Race : Minangkabau

A. Internal Satus

General Condition : moderate

Blood Pressure : 120/70 mmHg

Pulse rate : 84x per minute, regular

Respiratory rate : 21x per minute, reguler

Temperature : 36,80C

Height : 155 cm

Weight : 50kg

Respiratory System : in normal range

Cardiovascular Sytem : in normal range

Digestive System : in normal range

Genital System : was not performed

Spesific Disorder : was not found

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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 : can be moved in any direction, nistagmus

negative

▪ Perception : diplopia negative

▪ Pupil : round, isochors,

▪ Lights reflex : positive / positive

▪ Convergence reflex : positive / positive

▪ Cornea reflex : was not performed

▪ Ophthalmology : was not performed

◦ Motoric

▪ Tone : normal

▪ Turgor : good

▪ Strength : 555/555

555/555

▪ Coordination : Good

▪ Reflex :

Physiologic (patella) : positive/positive

Pathologic (babinsky) : negative/negative

◦ Sensibility : smooth and rough are good

◦ Vegetative neuron : eating, sleep, and wake normal

◦ Supreme functions : reading, writing, drawing, memory, and

language done well

◦ Spesific disorder

▪ stiffness : none

▪ tremor : none

▪ nasal stiffness : none

▪ occulogiric crisis : none

▪ torticolis : none

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ALLOANAMNESA

Name : Mr S.

Address/ phone. : Villa anggrek E19 air dingin / 081374101xxx

Occupation : employee

Education : 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 : born spontaneously, no history of cyanosis, jaundice, or

seizure.

- Childhood : Growth and development appropriate with age

- Teenage : pray five times a day, has many friends

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 doesn’t work

7. Social and economic background

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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

didn’t take medication regularly

2011 2012 10 11

AUTOANAMNESIS (November 12nd 2012)

Pertanyaan Jawaban Interpretasi- Sore buk, awak tanyo-

tanyo stek yo?- Sia namonyo buk? - Bara umur buk?- dima ibuk tingga?- ado ibu mandanga-

danga suaro-suaro?

- Yo pak

- Namo awak "M"- 57 tahun- di sijunjuang- iyo ado, anak wak

ngecek ka awak, nyo manangih-nangih tadanga dek awak

- Kooperatif

halusinasi akustik (+)

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-- Ado mengecek ka ibu?

caritoalah buk..--- Ado ibuk manampak

anak ibuk waktu tu?caritoanlah buk..

-- ada ibuk mancium-

cium 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 mancaliak urang

- ado ndak ibuk maraso

-

- indak, nyo manangih senyo.

-- iyo ado, nyo pakai

baju putih, puceknyo bantuaknyo.

- indak ado tabaun apo-apo do.

- 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 gara-gara awak. ibo hati wak jadinyo

- indak ado--

halusinasi visual (+)

halusinasi olfaktorik (-)

halusinasi taktil (-)

delution of control(+)

curiga (+)

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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 : composmentis / good

Attitude : cooperative

Motoric : active

Facial expression : rich

Verbalization : can speak, quite fluent

Physic contact : could be done/quite appropriate/quite long

Attention : present

Initiative : present

2. Specific condition

A. Affective

1. Affective condition : inapropriate

2. Emotional :

a. Stability : labil

b. Control : less

c. Echt/Unecht : Echt

d. Einfuhlung : inadequate

e. Deep/shallow : shallow

f. Differentiation scale : narrow

g. Emotional flow : fast

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B. Intelectual function and condition

a. Memorization ability : good

b. Concentration : decrease

c. Orientation : good

d. knowledge : hard to asses

e. Discriminative insight : disturbed

f. Intelligence prediction : normal average

g. Discriminative judgement : disturbed

h. Intelectual decreasing : none

C. Sensation and perception abnormalities

a. illusion : none

b. hallucination

- accoustic : present

- visual : present

Since 4 weeks ago, it still presents.

- olfatoric : none

- gustatoric : none

- tactile : none

D. Thought process condition

1. Speed of thought process: fast

2. quality of thought :

a) clear and sharp : clear less and sharp less

b) incoherent : none

c) Sperrung : none

d) Hemmung : none

e) Flight of ideas : none

f) verbigeration : none

g) preservation : none

3. Thought condition

a) Central pattern : none

b) phobia : none

c) obsession : none

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d) delusion : present, delusion of control

e) suspicion : present

f) confabulation : none

g) repultion : none

h) inferior feeling : none

i) Much/little : much

j) feeling guilty : none

k) hypochondria : none

l) others : none

E. Instingtual drive and behaviour abnormalities

a) abulia : none

b) stupor : none

c) raptus/impulsivity : none

d) excitement state : none

e) sexual deviation : none

f) echopraxia : none

g) vagabondage : present

h) pyromani : none

i) mannerism : none

a) others : none

F. Over anxiety : present, much

G. Reality testing ability : disturb in behaviour, thinking and

feeling

RESUME MULTIPLE AXIS

Axis I. Clinical Syndrome

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 :

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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 daughter’s death

Didn’t take the medication regularly

her grandmother has mental disorder

Axis V. Global assesment of function

social relation : social activity could not be done since 4 weeks ago

free time activity : mostly spend her time at home, no interest to have

outdoor activity since 4 weeks ago

Daily activity : eating, bathing as before

Multiple Axis Diagnosis

I. F.20.0 Paranoid Schizophrenia

II. no diagnosis

III. no diagnosis

IV. didn’t take medication regularly

V. GAF 51-60

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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 : dubia et bonam

Functional : dubia et bonam

Social : dubia et bonam

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