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Bed Side Teaching
SCHIZOAFFECTIVE DISORDER MANIC EPISODE
By
ANNISA FITRI P.1198
ATIKAH DAFRI P.1200
Preceptor
dr. Yaslinda Yaunin, Sp.KJ
Department of Psychiatric
MEDICAL FACULTY OF ANDALAS UNIVERSITY
DR. M. DJAMIL HOSPITAL
PADANG
2013
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Case Report
A 31 years old man was hospitalized in HB Saanin Mental Hospital since July 20th,
2013. He was brought to the hospital by his brother because he often went outside and walk
around the house without any purpose, and only came home after his family picking him up. He
was talk so much, talking and laughing by him self and lack of sleep ( 3 4 hours a day ). These
symptomn have happened since 2 months before admission to the hospital. Its the first time of
sicknesss and hospitalized.
Patient identity:
Name : Monra
MR : 010577
Gender : Male.
Age : 31 years old
Marital status : Married for the second time.
1st 2007. Devorced officially in 2008 ( reason : presence of
Third Person )
2nd
2011. Devorced unofficially on January 2013
Address : Tanjung Haro Sikabu, Padang Panjang Luak, Payakumbuh.
Occupation/Graduate from : Driver/ The 2
nd
year of Senior High SchoolReligion : Islam
Citizen : Indonesian
Ethnic : Minang
A. Internal StatusGeneral appearance : Modarate
Consciousness : Composmentis
Blood pressure : 120/80 mmHg
Pulse : Easily palpable, regular, 84 times per minute
Respiration : Abdominothoracal pattern, regular, 20 times per minute
Temperature : 370C
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Body Shape : Astenikus
Height : 160 cm
Weight : 50 kg
Cardiovascular system : No abnormality detected
Respiratory system : No abnormality detected
Digestive system : No abnormality detected
Specific disorder : No abnormality detected
B. Neurological StatusCranial Nervous (five senses) : Vision, smelling, hearing, tasting, and tactil are normal
Meningeal Signs : Neck stiffness (-)
High Intracranial Pressure Signs : Projectile vomiting (-), progressive headache (-)
Eyes
- Movement : Free to all direction- Perception : No nystagmus, no diplopia- Pupil : Round and isochor- Light Reflex : +/+- Convergence Reaction : Not examined- Ophtalmoscopic examination : Not examined
Motoric
- Tonus : Eutonus, tremor (+/+)- Turgor : Good- Strength : 555 555
555 555
- Coordination : Good- Reflex : Physiologic (Patella) ++/++, pathologic (Babinsky) -/-
Sensibility : No abnormality detected
Vegetative Function : No abnormality detected
Basic Function : No abnormality detected
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Specific disorder
- Rigidity : None- Tremor : None- Nasal Stiffness : None- Oculogyric Crisis : None- Torticolis : None- Others : None
Autoanamnesis, July 29th
2013:
Question Answer Interpretation
Assalamualaikum Pak... Waalaikumsalam.. Consciousness
composmentis
Pak, awak pareso sambia maota
lamak yo, pak ?
Ambo ka dipareso... Jadih... Cooperatif
Ambo dokter muda Atikah, iko
kawan ambo Dokter Muda
Annisa. Kalau namo apak sia,pak ?
Jadi adiak - adiak ko dokter
muda. Namo ambo Monra
Good Attention
Bara umua Apak kini, Pak? Ambo lahia tahun 82. Umua
ambo lah 31 tahun kini.
Time orientation is good
O alah 31 tahun. Alah
manikah apak?
Alah.
Bara urang anak apak? Baduo. Induaknyo duo lo. Personal Orientation is Good
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Duo ba a induak nyo ko pak?
Iyo, ambo lah duo kali
manikah. Ciek anak dari bini
patamo, ciek lai dari bini
kaduo. Lakilaki kaduonyo.
Bapakai duoduo nyo kini
pak?
Indak. Alah carai dari bini
patamo tahun 2008. Apak
nikah liek tahun 2011. Tapi
kami lah pisah rumah lo sajak
7 bulan patang.
Good Memory
Ba a kok bisa bapisah, pak? Nan patamo dek ado urang
katigo di bini ambo. Nan
patang ko dek istri ambo ndak
nuruik do. Nyo ndak nio
dilarang stek alah do. Ambo
kicek jan makan ayam, sadang
banyak flu buruang waktu tu
di Payakumbuah. Nyo mada
juo. Tu ndak suko nyo ambo
laranglarang. Makonyo kini
ambo tingga jo urang tuo
ambo. Nyo tingga di Limo
Puluah Kota, ambo di
Payakumbuah jo anak kami.
Situation Orientation is Good
Place Orientation is Good
Jadi urang tuo apak yang
mambaok apak ka siko?
Indak. Uda jo adiak ambo. Personal Orientation is Good
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Dek apo apak dibaok ka siko? Ndak tau do. Tibotibo se
ambo dibaok ka siko..
Discriminative insight is
distracted
Iyo ambo dek paipai se
ndak tantu arah. Pai kama
kama
Vagabondage ( + )
Ndak tantu apak kama pai? Tu
ba a kok bisa pulang?
Iyo nyo turuik an jo keluarga
ambo. Ko ndak nyo cari nyo.
Tu dibaok nyo ambo pulang.
Ba a kok apak paipai se?
Nampak jo apak, padusi atau
lakilaki urangnyo? Ba a kok
apak namuah se nyo kicek an?
Io. Ado yang mambisiak an ka
ambo, pai kalua. Pai kalua.
Jalan taruih. Makonyo ambo
pai.
Ndak nampak jo ambo do, tapi
suaronyo suaro lakilaki.
Iyo, ndak tau do. Ndak ado
dayo ambo manulak do. Ambo
raso dikendalikannyo jo suaro
tu.
Tu kadang nyo sabuik lo.
Ambo kan puaso juo,
sembayang juo. Nyo kicek an,
untuak a sembayang tu?
Auditoric Hallucination ( + )
Delusion of Control ( + )
Auditoric Hallucination ( + )
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Untuak a puaso tu? Ndak usah
lai. Untuak apo lo tu.
Thought Insertion ( + )
Tu apo kicek, apak?
Tapi kicek keluarga apak,
apak ngicekngicek surang,
galakgalak surang?
Ndak aso do ambo diam se
nyo.
Kalau ngicekngicek surang
tu ba a yo buk. Pikiran ambo
ko raso ado yang
manghalangi, raso ado yang
manghambek. Kadang sampai
angek rasonyo. Jadi tu
baguman se ambo. Tapi ndak
manjawek suaro tu do.
Kalau galakgalak tu iyo
buk. Tapi ndak mandanga ado
yang lawak do. Raso ado yang
manarik bibia ambo ko bu,
manyunggiangkan muluik ko.
Tu mako ambo nampak galak.
Ado lo yang mamacikmacik
ambo rasonyo.
Blocking and Inhibition ( + )
Dellusion of Passivity ( + )
Tactil Hallucination ( + )
Ndak nampak tapi ado
suaronyo yo pak yo?
Ba a kok bisa batamu Nabi
Muhammad apak? Nampak
Iyo. Tapi pernah waktu duo
bulan yang lalu, Ambo katamu
Nabi Muhammad.
Iyo. Miripmirip Roma
Irama tu lah. Beliau ngicek ka
ambo, ko jalan nan luruih. Ko
Visual and Auditoric
Hallucination ( + )
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bantuak Nabi jo apak? jalan nan salah. Ko pegangan
iduik yang rancak. Turuik kan
lah yang rancak.
Sajak bilo nampaknampak
jo tadangatadanga suaro tu?
Sajak 2 bulan yang lalu tu lah.
Waktu tu ado tabaunbaun
sesuatu ndak jo apak?
Ndak ado do Olfactoric Hallucination ( - )
Jadi manuruik apak, wajar
ndak apak dibaok di rumah
sakik jiwa ko?
Yo..., ambo malu. Manga
patang galakgalak surang,
jalan ntah kamakama.
Discriminative Insight is good
Kalau kini ndaka do tadanga
danga, atau nampak, atau
tarasoraso yang patang tu
lai pak?
Lah indak ado lai do
Patang tu ba a kok bisa sakikapak? Dek apo kirokiro tu
pak?
Iyo, mungkin dek ambobanyak pikiran. Ambo taragak
ndak ka babaliak jo bini ambo.
Stressor ( + )
Taragak bana, pak? Dek itu
apak sadiah?
Sadiah ndak lo do. Tapikia se
untuak apo babini bapacar
pacar banyak, ancak ciek se
lai. Tapi kicek bini ambo nyo
pikiapikia lu, alum bisa kinilai.
Loh, banyak pacar apak tu? Iyo ka patangpatang tu. Tu
patang ko ambo taragak jo
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Ndak berang bini apak, apak
bapacarpacar?
Banyak pemasukan apak jo
nyupir tu? Supir apo apak?
bini se lai.
Iyo berang juo nyo. Tapi sado
kandak nyo dek ambo turuik
an. Ambo royal ka bini ambo.
Ka pacar ambo gai. Kadang
malam minggu tu bali bakso,
baok kawankawan nyo gai.
Ambo bayia kan.
Ambo supir angkot. Yo lai
lah, balabiahlabiah. Bisa
manuruikkan kandak padusi
padusi tu. Kadang pai jo
kawan bagai, ambo traktir.
Ambo ndak pilikpilik do.
Symptoms of Manic
Delusion of greatness ( + )
Dek itu apak banyak suko
padusi ka apak?
Iyo. Ambo bailmu. Sajak
2001. Tapi lah ambo buang
sajak 2010. Takuik beko ado
apoapo.
Delusion of greatness ( + )
Ilmu ba a ko, Pak? Apak
mintak atau diagiah?
Iyo ambo yang mintak. Ambo
tuntuik. Pamanih, pamaga.
Tapi lah dibuang, lah 3 tahun
lalu.
Delusion of greatness ( + )
Jadi kini ndak punyo lai do? Ndak punyo lai do.
Kalau mandi, apak biasonyo
lamolamo, pak?
Indak. Biaso se nyo. Sabanta
se
Hydromani ( - )
Suko mambakabaka,
mancaliak api gadang suko
Indak. Ndak pernah apak Pyromani ( - )
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pak? mambakabaka do.
Nah kini apo yang taraso dek
apak? Sanang apo sadiah?
Yo kini lah lamak rasonyo.
Ndak ado yang tadanga
danga, nan nampak lai do.
Positive symptoms are
decreased.
Tu kalau lah kalua apak dari
siko, apo rencana apak?
Yo, supo biaso. Karajo. Tu iyo
ambo yo ka nak babaliak jo
bini ambo.
Abulia ( - )
Manyasa apak ba a kok apak
pisah patang?
Inyo yang manyasa kiceknyo.
Tapi inyo gengsi lo. Ambo
taragak se nyo. Kami pisah
dulu ndak dek salah ambo,
tapi dek inyo ndak namuah
nuruik, tu nyo pai se.
Guilt ( - )
Tapi apak ndak ka bapacar
pacar liek?
Hehehe, yo ndak lai do..
Yo lah pak, lah banyak
bakurang sakik apak rasonyo
yo kini? Makan lalok ba a?
Yo lah, apak istirahat lai yo
pak. Makasih yo pak
Iyo alah dok. Alah tanang
rasonyo kini. Lalok lamak,
makan namuah.
Samosamo dok.
Alloanamnesis was given by:
Name/Age : Mr. Eki Susandra/27 years old
Address : Tanjung Haro Sikabu, Padang Panjang Luak, Payakumbuh.
Telephone number : 085263111760
Occupation : Unemployement
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Relationship with patient : Brother
Primary cause of hospitalization
Went outside and walk around the house without any purpose, and only came home after
his family picking him up. He was talk so much, talking and laughing by him self and lack of
sleep ( 34 hours a day ). These symptomn have happened since 2 months before admission to
the hospital. Its the first time of sicknesss and hospitalized.
Present complain of patient
There is no complaint at this time.
History of illness:
2013 ( May )
Patient went outside and walk around the house without any purpose, and only came home after
family picking him up. He was talk so much, talking and laughing by him self and lack of sleep (
34 hours a day ). He was brought to a shaman by his family. But there is no improvement.
At the previous, patient asked his wife for live with him again, but she rejected. They were
separated since January 2013. But he had some girlfriends along that time.
2013 (July)
Patient is brought to the HB Saanin Mental Hospital by his family because he show no
improvement.
Premorbid history
Infant : born spontaneously, birth was assisted by midwife, no history ofjaundice, cyanosis, and seizure.
Childhood : growth and development according to his age.
Adolescence : growth and development according to his age.
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Adult : growth and development according to his age. Had a lot of friends, an
outgoing person.
Occupation history
Patient is a driver.
Educational background
Elementary School at Lakuak Damar, Payakumbuh. Graduated in 6 years
Junior High School at Situjuah nan Gadang. Graduated in 3 years.
Senior High School at Kasgoro untill the 2nd
year because he was more interested in working (
as a driver ) than studying.
Marriage history
1st 2007. Devorced officially in 2008 ( reason : presence of Third Person ).
2nd
2011. Devorced unofficially on January 2013
Social economy history
Patient was a driver. He feels good with his economic life.
Family history of illness
P
There is no family members who has similar symptomns or any mental sickness.
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EXPLANATION AND CONCLUSION OF PSYCHIATRIC EXAMINATION
Examination is on July 29th
2013
1. General appearanceConsciousness/sens : composmentis/good
Attitude : cooperative
Motoric : active
Facial expression : rich
Verbalization : speak clearly and fluently
Physic contact : reacheable, fair, long enough
Attention : Adequate
Initiative : Good
2. Specific conditionA. Affective
1. Affective condition : eutym2. Emotional :
a. Stability : Stableb. Control : Goodc. Echt/unecht : echtd. Einfuhlung : Inadequate. Deep/shallow : deepf. Differentiation scale : wideg. Emotional flow : fast
B. Intellectual condition of functiona. Memory : goodb. Concentration : goodc. Orientation : goodd. General and schooling knowledge : average normale. Discriminative insight : distractedf. Intelligence prediction : average normal
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g. Discriminative judgment : distractedh. Intelectual deterioration : none
C. Sensation and perception abnormalities1.Illusion : none2.Hallucination :
Auditoric : positive
Visual : positive
Olfactory : none
Tactile : positive
Gustatory : none
D. Thought process condition1. Speed of thought processs : fast2. Quality of thought process:
a. Clear and sharp : clear and sharp enoughb.Circumstantial : nonec. Incoherent : noned.Blocking : positivee. Inhibition : positivef. Flight of ideas : noneg.Verbigeration : noneh.Preservation : none
3. Thought conditiona. Central pattern : noneb.Phobia : nonec. Obsession : noned.Delusion : presente. Suspicion : presentf. Confabulation : noneg.Repulsion : presenth.Inferior feeling : none
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i. Much/little : muchj. Feeling guilty : nonek.Hypochondria : nonel. Others : none
E. Instinctual drive and behavior abnormalitiesa. Abulia : noneb.Stupor : nonec. Raptus/impulsivity : noned.Excitement state : nonee. Sexual deviation : nonef. Echopraxia : noneg.Vagabondage : presenth.Pyromania : nonei. Mannerism : nonej. Others : none
F. Over anxiety : noneG. Reality testing ability : disturb in behavior, feeling and thinking
MULTIPLE AXIS RESUME
Axis I. Clinical Syndrome
Went outside and walk around the house without any purpose, and only came home after his
family picking him up. He was talk so much, talking and laughing by him self and lack of sleep (
3 4 hours a day ). These symptomn have happened since 2 months before admission to the
hospital. Its the first time of sicknesss and hospitalized.
Phsyciatric examination:
General Appeareance: composmentis, cooperative, active, rich, can speak clearly and fluently,
psychic contact is reachable, fair, and long enough.
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Specific condition:
a. Affective condition: eutym, stable, much, echt, inadequate, deep, wide, fast.b. Intellectual condition and function: good memory, concentration is good, good
orientation, absent intelectual deterioration, discriminative insight and judgment are
disturbed.
c. Sensation and perception abnormalities: Presence of auditoric, visual, and tactilhallucination.
d. Thought process condition: fast, clear and sharp enough, no central pattern, delusionpresent, much, coherent, presence of blocking and inhibition,
e. Instinctual drive and behavior abnormalities: vagabondage present.f. Overt anxiety: noneg. Reality testing ability, disturbed in behavior, feeling and thinking
Axis II : Personality Disorder and Mental Retardation Disorders
Personality disorder : none
Mental retardation : none
Axis III : General Medical Condition
No history of head trauma, malaria, typhoid, or any other disease which it needs treatment in
hospital
Axis IV : Phsychosocial Stressor and Environment
Patient was rejected by his wife for living together again.
Axis V: Global Assessment of Function
Daily activities ( working, helping family, cleaning the house ) couldnt be done sincethe illness
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Social relationship ( visiting friends, mutual support, recitals ) couldnt be done sincethe illness
Leisuring time ( travelling, watcing tv ) couldnt be done since the illness
MULTIPLE AXIS DIAGNOSIS
I. F.25.0 Schizoaffective Disorder Manic EpisodeII. No diagnosis
III. No organic disorderIV. Rejected by his wife for living together againV. GAF 41-50.
DIFFERENTIAL DIAGNOSIS
I. F 30.2 Affective Disorder Manic Episode with Psycotic SymptomsII. F 20.0 Paranoid Schizophrenia
THERAPY
Lodomer + Diazepam injection @ 1 ampul Risperidon 2 x 2 mg Amitriptyline 2 X 12,5 mg CPZ 1 x 100 mg (night)
PROGNOSIS
Clinical : dubia at bonam
Functional : dubia at bonam
Social : dubia at bonam
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