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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.


Ilmu ba a ko, Pak? Apak

mintak atau diagiah?

Iyo ambo yang mintak. Ambo

tuntuik. Pamanih, pamaga.

Tapi lah dibuang, lah 3 tahun

lalu.


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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