Skizofrenia Herbefrenik

Heri Fitrianto

Muhammad Iqbal

P. 1483

P. 1489

CASE REPORT
A 31 years old female patient, came to the Mental Polyclinic of
M.Djamil Hospital Padang on October 27, 2014 at 01:00 pm and
escorted by her mother. The Patient tried to kill herself by using knife
before coming to the hospital. This is the first attack, hospitalization
for the three times too. The symptoms felt now is more severe than
the previous one.

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 School (until
5th grade )
Citizen
:
Indonesian
Tribe :
Minangkabau
Address
:
Komplek Tarok I J/18, Kecamatan Kuranji Kota Padang

 Internal Status
General appearance : Composmentis
Blood pressure : 120/80 mmHg
Pulse
: palpable, regular, 82 times per minute,
Respiration
: toracoabdominal, regular, 18 times per minute
Temperature
: 36,70C
Body Shape
: normal
Height
: 158 cm
Weight
: 47 kg

 Respiratory system
:

Inspection : Symmetrical on both left and right site in static

and dynamic state

Palpation :
Fremitus left side equal to the right side

Percussion :
Sonor throughout the lung fields

Auscultation :
Vesicular breath sounds, no ronkhi, and no
wheezing

 Cardiovascular system :

Inspection :
Ictus is not visible

Palpation
:
Ictus was palpable 1 finger on the
medial side of LMCS RIC V

Percussion :
Cardiac border was obtained normal

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

 Gastrointestinal system :

Inspection
:
no bulge

Palpation
:
Liver and spleen were not palpable

Percussion
:
tympanic

Auscultation :
normal intestinal murmurs

specific abnormalities
: not found

 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, 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
: was not performed
Cornea reflex
: was not performed
Ophthalmology
: was not performed

 Motoric
Tone
: Eutone
Turgor
: good
Strength
: 555 555

555 555
Coordination
: Good
Reflex
:
Physiologic (patella)
: ++/++
Pathologic
: Babinsky reflex negative

 Sensibility
: smooth and rough were good
Vegetative neuron : eating, sleeping, and waking function were normal
Supreme functions
: Activity of reading, and languange can be
performed well, writing,, drawing,, and numeracy cannot be performed
well
Spesific disorder
stiffness
: none
tremor
: none
nasal stiffness
: none
occulogiric crisis : none
torticolis
: none

 Laboratory Test
28 Oktober2014
HB = 14,3 g/dl
Ht = 44,4%
Platelet = 264.000 /mm3
Leukocytes = 7.400 / mm3

ALLOANAMNESIS
Name / Age
: Mrs. S/ years old
Jenis Gender
: Female
Address/phone : Komplek Tarok I J/18, Kecamatan Kuranji Kota
Padang
Occupation
: Noodle Sellers
Education : Ungraduated form elementary school
Relationship with the patient : Patient's mother


Main reason for hospitalization
Patients tried to suicide with knife.
Current Chief Complain: Patient have thougt theres no reason for her to live
anymore

Past History of illness

2002
Patient was irritable suddently, threated others, and ruined everything at her
house. Ever since patient often was brougt to the hospital by her family and got
hospitalized at Dr. M. Djamil Padang Hospital and HB. Saanin Hospital. Patient
tried to kill herself by drinking baygon several times. Patient also hit her head to
the wall and throw her self to the car.

 Her mother often brought her to the hospital if her symptoms

relapsed. Sometimes patient regularly took medicine but sometimes
not. Patient got iritated when someone remembering her to take
medicine.
2012
Patient got married with her mother friends son and her husband
dumped her away. They didnt contact each other anymore. The
patient wanted to find her husband but she hadnt enough money.

 2013
She stole her cousin dress and brought to her sister house. She got
busted by her cousin and her cousin sended her to Dr. M. Djamil
Hospital again.
2014
Patient tried to suicide again by using knife after she got instruction
by demon but she had busted by her mother and then her mother
brought her back to Dr. M. Djamil Hospital

 Premorbid History
Infant
: born spontaneously, aterm, attended by midwives, no
history of cyanosis, jaundice, or seizure.
Childhood : Growth and development were appropriate with his age
Teenage : Growth and development were appropriate with
teenagers on his age, but she had goofy face and irritable.

 III. Educational Background

Elementary school : ungraduated in third year because her family

had 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 is a
permanent one, there is electricity, the source of water is from wells.
Patient hadnt vehicle.

VII. Family History

VII.

Graphic of illness

2002

2013

2014

AUTOANAMNESIS
Questions
Assalamualaikum, perkenalkan
buk kami dokter muda di siko.
Namo awak Heri, ko kawan awak
Iqbal. Sia namo ibuk?
Buliah awak mananyo nanyo ibuk
sabanta?
Bara umua ibuk? Bilo ibuk lahia?
Hari apo kini buk?
Tanggal bara kini buk?
Limo hari lai hari apo buk?
Ibuk tau dima kini?

Answers

Ayu, Sri Wahyuni.

Buliah

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?

Interpretation

Jo amak ambo ka siko.

Kooperatif, orientasi waktu

terganggu, orientasi tempat
tidak terganggu, orientasi
personal tidak terganggu.

A nan ibo kini raso?

A nan sakik jo ibuk?

Indak Ado do
Ambo ndak meraso sakik

Lah ka bara kali ibuk dibaok 3 kali

kasiko?
Baa ko ibuk dibaok ka siko?

Nio barubek kulit yang gata gata

Tahun bara pertamo kali 2009

kasiko?
Dek a tu kasiko dulu buk?

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.

Discriminative insight
terganggu

Kecek amak ibu, ibuk nio bunuh diri. Ambo disuruh setan.
Dek a tu?
Waktu tu, apo kecek setan tu?
Waktu tu, nampak ndak setannyo?

Ndak ado guno iduik, mati se lah lai.

Waktu tu, ado nan ta baun ndak Hitam setannyo

buk?
Waktu tu, ado nan taraso?

Ado, bau angik (busuk)

Halusinasi visual, audio, taktil,

olfaktori ada.

Ado, tangan ibu di rese jo setan.

Ibuk ka dapek pitih saratui ribu di Bali cindua

jalan, ka ibuk pangaan pitih tuh?

Discriminative Judgment terganggu.

Ibuk

ado

maraso

punyo Ndak do

kekuatan ndak?bisa maubekan

urang?maraso urang hebat?
Sejak di siko ado taraso berang
Dendam tidak ada

jo amak yang baok ibuk ka siko?

Ado

indak

ibuk

curiga

jo Ndak do

kaluarga ibuk?
Curiga tidak ada

Kalau lalok baa buk?lai lamak?

Lai bisa.

Alah makan tadi buk?

Alah.

Ibuk, kalau pulang dari siko ka Ambo nio cuci piriang, mamasak buek
nio manga rencana?

abang

Tidur cukup
Makan cukup
Hubungan realitas terganggu
(sudah berpisah dengan suami
sejak tahun 2012)

Nah buk, jan pernah Iyo.

tapikia

jo

lai

tuak

bunuah diri yo buk yo,

ingek amak, amak lah

payah

mancari

pitih

untuk maubek buk ayu,

jan kecewakan amak
Aaa..Sagitu se dulu yo Iyo.
buk. Mokasi yo buk.

SUMMARY OF PSYCHIATRYCH TEST

I. General Appearance
Conciousness/ sensorial : composmentis / good
Attitude
: cooperative
Motoric
: active
Facial expression
: poor
Verbalization
: can speak, quite fluent
Psychic contact
: could be done, incoherent, appropriate, long
Attention
: present
Initiative
: less

 II. Specific condition

Affective
Affective condition
Emotional

a. Stability
b. Control
c. Echt/Unecht
d. Einfuhlung
e. Deep/shallow
f. Differentiation scale
g. Emotional flow

: Dull
:

: labil
: fair
: Echt
: inadequate
: shallow
: narrow
: slow

Intelectual function and condition

a. Memorization ability
: poor
b. Concentration
: decrease
c. Orientation
: disturbed in terms of time and
place
d. knowledge
: hard to asses
e. Discriminative insight
: disturbed
f. Intelligence prediction
: below average
g. Discriminative judgement
: disturbed
h. Intelectual decreasing
: none

 Sensation and perception abnormalities

a. illusion
: none
b. hallucination
- accoustic
: present

- visual
: present

- olfatoric
: present

- tactile
: present

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

 Instingtual drive and behaviour abnormalities

abulia
: none
stupor
: none
raptus/impulsivity
: none
excitement state: none

sexual deviation : none

echopraxia
vagabondage
pyromani
mannerism
others

: none
: none
: none

Overt anxiety
Reality testing ability

: none
: none

: none
: disturb in behaviour, thinking and feeling

 MULTIPLE AXIS RESUME

Axis 1. Clinical Syndrome
The Patient tried to kill herself by using knife before coming to the
hospital. This is the first attack, hospitalization for the three times too.
The symptoms felt now is more severe than the previous one.
General appearance: composmentis cooperative, sensorial is fine,
Attention is good, initiative is less, motoric active, facial expression is
poor, verbalization influent, psychic contact could be done, abnormal
and long.

 Specific condition
Affective condition : dull, labil, less, echt, inadequate, shallow, narrow,
slow.
Intelectual condition and function: memorization ability poor, hard to
concentrate, orientation is disturbed in terms of time and place,
knowledge is hard to asses, discriminative insight disturbed,
intelligence prediction is hard to asses, discriminative judgement
disturbed.

 Sensation and perception abnormalities: no illusion, acoustic,

olphactoric, visual and tactile hallucinations are present
Thought process condition : Slow, incoherent, and little.
Reality testing ability : disturbed in behaviour, thinking and feeling

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

 Multiple Axis Diagnose

F 20.1 Skizofrenia herbefrenik
No Diagnose
No Diagnose
No Diagnose
GAF 41-50

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

PROGNOSE
Penilaian

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

Abstence

Disorder

 Clinical
: dubia et malam
Functional : dubia et malam
Social
: dubia et malam

Thank You