CRS Skizofrenia Residual

7/25/2019 CRS Skizofrenia Residual

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CASE REPORT

PRESEPTOR:

H. R. M. Haryadi Kartono, dr., SpKJ

DISUSUN OLEH:

Hena Arlini !!"#""$%Anant&a Ra' (ane)an !!"#*"%"

Tanggal 15 JUNI 2006

BAGIAN ILMU KESEHATAN JIWA

RUMAH SAKIT HASAN SADIKIN

FAKULTAS KEDOKTERAN UNIERSITAS PADJADJARAN

BANDUNG


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2006

A. KETERANGAN UMUM

DATA PASIEN

Na!a " Tn# AD

U!$% " 25 &'

J(n)* K(la!)n " La+),la+)

Ala!a& " P(+al-ngan. La!/$ng,U&a%a

Aga!a " I*la!

S&a&$* Ma%)&al "B(l$! n(n)+a'

P(n))+an " SMA

P(+(%aan " Sa*&a. agang

Tanggal Ma*$+ R$!a' Sa+)& " 06 J$n) 2006

KETERANGAN HETEROANAMNESA DIPEROLEH DARI

Na!a " Ena%a*)'

U!$% " 53 &'

J(n)* K(la!)n " P(%(!/$an

Ala!a& " P(+al-ngan. La!/$ng,U&a%a

H$4$ngan " I4$ Kan$ng

B. KELUHAN UTAMA

Ma%a',!a%a' &an/a *(4a4. &(lanang. 4)a%a +aa$. !(!$+$l

)4$na

C. RIWAYAT PENYAKIT SEKARANG

P* &)4a,&)4a !a%a',!a%a' &an/a *(4a4 *a!/a) !(!$+$l )4$na#,78 1 4$lan SMRS P* *(%)ng &)4a,&)4a &(lanang. !an),!an) )

/a*)% (ngan ala*an $n&$+ !(ng'a/$* -*a# P* $ga *(%)ng 4ana+

4)a%a &(n&ang +(')$/an 9a!an S-(+a%n- an S-('a%&-# P* *$l)&

&)$% &an/a *(4a4. an &)a+ !a$ !a+an#


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,78 2 4$lan SMRS P* *(%)ng 4)a%a *(n)%) )+a )&ana+an P*

4)a%a (ngan n(n(+na ang *$a' !(n)nggal#

P* !(nga+$ *(%)ng !(n(nga% *$a%a,*$a%a ang !(n$%$'na

!(nga+$ *(4aga) T$'an. Na4) a&a$ D(a *la)n $&) P* $ga !(nga+$

a/a& !(l)'a& J)n I*la!#

D. RIWAYAT PENYAKIT DAHULU

Ta'$n 2000 )%aa& ) Bag# P*)+)a&%) RSHS *(&(la' l$l$* SMA an

4(%+()ng)nan !(lan$&+an /(n))+an +( IKJ &(&a/) &)a+ a/a&

)/(n$') -l(' -%ang &$a +a%(na +(&(%4a&a*an 4)aa an )a%a'+an +(

+(/-l)*)an &(&a/) &)a+ 4(%'a*)l !a*$+#

Ta'$n 200: )%aa& ) B-g-%

M() 2006 )%aa& ) RS La!/$ng +a%(na g(l)*a'. !a%a',!a%a'. &)a+

4)*a &)$% an &)a+ !a$ !a+an

R)aa& /(ngg$naan NAP;A &a'$n 1


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(4%)*

P(!(%)+*aan *)+ la)n " ala! 4a&a* n-%!al

J. STATUS PSIKIATRIKUS

K(aaan U!$! " &(nang

K(*aa%an " CM

R-!an !$+a " 4)a*a *aa

P(%'a&)an " $+$/K-n&a+7Ra//-% " a(+$a&

O%)(n&a*) " WTO &)a+ &(%gangg$

P(%*(/*) " )l$*) ,. 'al$*)na*) (nga%,)*$al 8

P)+)%an " a$&)*&). +(!)*+)nan )(

T)ng+a' la+$ " n-%!-a+&)>


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IOI " Pa%*)al

M--7a>(+ " 4)a*a7 a//%-/%)a&( (ngan !--

D(-%$! " S-/an *an&$n $+$/

B(%/a+a)an $+$/

K(4(%*)'an $+$/

K. LABORATORIUM

H4 " 1?.1 g%7L

L($+-*)& " 6100 7!!?

H(!a&-+%)& " ::

T%-!4-*)& " 121000 g%7L

SGOT " 20 g%7L

SGPT " 13 g%7L

U%($! " 20 g%7L

K%(a&)n)n " 0.< g%7L

GDS " 3= g%7L

L. PSIKODINAMIK

P* *(-%ang la+),la+) 25 &a'$n. aga!a I*la!. ana+ +( = a%) =

4(%*a$a%a F# P%()*/-*)*)

Ma*a 4a) )4(%) ASI : 4$lan +(!$)an )&)nggal+an )4$na. an

)4$ P* )%aa& ) Bag#P*)+)a&%) RSHS *(la!a 1.5 4$lan

F#P%()*/-*)*)

Ma*a +ana+,+ana+ an /%a*(+-la' &)a+ )aa%+an -l(' )4$na.

*(%)ng )&)nggal+an -l(' -%ang&$a $n&$+ 4(+(%a an 'ana )a*$'

-l(' /(!4an&$ %$!a' &angga F#P%()*/-*)*)

Ma*a *(+-la' l(4)' *(nang 4(%!a)n ) %$!a' an &(&angga +a%(na

*(%)ng )&)nggal+an -%ang &$a $n&$+ 4(+(%a an 4(%+(!4ang

!(na) -%ang ang /(n)a! F#P%()*/-*)*)

R)aa& /(ngg$naan NAP;A an al-'-l *aa& *(+-la'

F#P%()*/-*)*)


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K(/%)4a)an P* /(n)a!. &(%&$&$/. &)a+ !(!)l)+) &(!an (+a& an

&)a+ aa +()ng)nan $n&$+ 4(%ga4$ng ala! +(g)a&an *-)al

4(%+(l-!/-+ F#P%-!-%4)

3 &a'$n ang lal$ P* *(&(la' l$l$* SMA )ng)n !(lan$&+an

/(n))+an +( IKJ &(&a/) &)a+ )/(n$') -l(' -%ang &$a +a%(na

+(&(%4a&a*an 4)aa. an &)a+ 4(%'a*)l !a*$+ K(/-l)*)an# K((a

&)a+ 4(%'a*)l !(lan$&+an /(n))+an F#P%(*)/)&a*)

M.DIAGNOSA MULTIAKSIAL

A+*)* I " F20#5 S+)9->%(n)a R(*)$al

A+*)* II " F60#?0 Gangg$an K(/%)4a)an E!-*) Ta+ S&a4)l T)/(

I!/$l*)>

A+*)* III " &)a+ aa

A+*)* I " &)a+ aa

A+*)* " GAF *aa& /(!(%)+*aan" 60,51 g(ala *(ang. )*a4)l)&a*

*(ang

N. PENGOBATAN

Hal-/(%)-l &a4 22.5 !g

C'l-%/%-!a9)n( 100 !g 172 , 0 , 172

O. PROGNOSA

$- a )&a! " a 4-na!

$- a >$n&)-n*! " $4)a a !ala!

P. PEMBAHASAN

a# D)agn-*)*

P* )g-l-ng+an *(4aga) /*)+-&)+ >$ng*)-nal. *+)9->%(n)a

%(*)$al +a%(na !(%$/a+an *$a&$ *&a)$! +%-n)* ala!


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/(%+(!4angan *$a&$ gangg$an *+)9->%(n)+. )!ana &(la'

&(%%a) /%-g%(*) a%) *&a)$! aal ang )&ana) *(a%a +'a*

-l(' g(ala,g(ala n(ga&)( ang+a /anang. ala$/$n

4(l$! &(n&$ )%((%*)4(l#

T(%a/a& 4(4(%a/a a%) /(%*a%a&an )agn-*&)" g(ala

n(ga&)( *+)9->%(n)a ang !(n-n-l. !)**al a+&))&a*

!(n$%$n. *)+a/ /a*)> an +(&)aaan )n)*)a&)>. +(!)*+)nan )*)

/(!4)a%aan. /(%aa&an )%) an +)n(%a *-)al ang 4$%$+

*()+)&n&a aa %)aa& *a&$ (/)*-( /*)+-&)+ !a*a la!/a$

*()+)&na !(la!/a$) +$%$n a+&$ *a&$ &a'$n (ngan

)n&(n*)&a* an >%(+$(n*) g(ala ang na&a *(/(%&) a'a!.

an 'al$*)na*)

T)a+ &(%a/a& (!(n*)a a&a$ /(na+)& gangg$an -&a+

-%gan) la)n

Gangg$an +(/%)4a)an ang )a/a& /aa P* !(%$/a+an

(!-*) &a+ *&a4)l (ngan &)/( )!/$l*)( )!ana &(%a/a&

+((n(%$ngan 4(%&)na+ )!/$l*)( &an/a /(%&)!4angan

+-n*(+$(n*). 4(%*a!aan (ngan +(&)a+*&a4)lan a>(+#

K(!a!/$an !(%(nana+an *(*$a&$ !)n)!al (ngan

+(!$ng+)nan l(a+an /(%)la+$. &(%$&a!a 4)la )+%)&)+ a&a$

)'alang) -%ang la)n#

4# T(%a/)

P(!4(%)an Hal-/(%)-l *(4aga) an&) /*)+-&)+ &)/)+al g-l-ngan

B$&%-/'(n-n( (ngan -*)* 22.5 !g /(% 'a%) a&a* )n)+a*)

)agn-*&) /*)+-*)* aana '(naa 4(%a& ala! +(!a!/$an

!(n)la) %(al)&a*. gangg$an a*-*)a*) /)+)%an. /(%*(/*).

/(%)la+$ ang an(' an &)a+ &(%+(nal). an '(naa ala!

+(')$/an *-)al#

C'l-%/%-!a9)n (ngan /(!4(%)an 100 !g /(% 'a%). $n&$+

(>(+ *(a*). !(n(+an ')/(%a+&))&a* an ag%(*))&a*


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# P%-gn-*)*

P%-gn-*a $- a )&a! a 4-na! +a%(na *a!/a) *aa& )n)

&)a+ aa ana!an !(!4a'aa+an )%) *(n)%) !a$/$n

+()ng)nan 4$n$' )%)#

$- a >$n&)-na! $4)a a !ala! +a%(na -n*(& /aa $*)a

!$a (ngan %)aa& /*)+-*)* +(l$a%ga. %)aa& /(na+)&

4(%$lang an /%-*(* /(n)la)an ang 4$%$+ (ngan %)aa&

/(ngg$naan NAP;A an al-'-l#

CRS Skizofrenia Residual

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