Bed Side Teaching

SCHIZOAFFECTIVE DISORDER MANIC EPISODE

By ANNISA FITRI ATIKAH DAFRI P.1198 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 MR Gender Age Marital status : : : : : Monra 010577 Male. 31 years old Married for the second time. 1st 2007. Devorced officially in 2008 ( reason : presence of Third Person ) 2 nd 2011. Devorced unofficially on January 2013 Address : Tanjung Haro Sikabu, Padang Panjang Luak, Payakumbuh. Driver/ The 2 nd year of Senior High School Islam Indonesian Minang

Occupation/Graduate from : Religion Citizen Ethnic : : :

A. Internal Status General appearance Consciousness Blood pressure Pulse Respiration Temperature : Modarate : Composmentis : 120/80 mmHg : Easily palpable, regular, 84 times per minute : Abdominothoracal pattern, regular, 20 times per minute : 370C
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Body Shape Height Weight

: Astenikus : 160 cm : 50 kg

Cardiovascular system : No abnormality detected Respiratory system Digestive system Specific disorder : No abnormality detected : No abnormality detected : No abnormality detected

B. Neurological Status Cranial Nervous (five senses) Meningeal Signs : Vision, smelling, hearing, tasting, and tactil are normal : Neck stiffness (-)

High Intracranial Pressure Signs : Projectile vomiting (-), progressive headache (-) Eyes Movement Perception Pupil Light Reflex Convergence Reaction Ophtalmoscopic examination : Free to all direction : No nystagmus, no diplopia : Round and isochor : +/+ : Not examined : Not examined

Motoric Tonus Turgor Strength : Eutonus, tremor (+/+) : Good : 555 555 555 555 Coordination Reflex : Good : Physiologic (Patella) ++/++, pathologic (Babinsky) -/: No abnormality detected : No abnormality detected : No abnormality detected

Sensibility Vegetative Function Basic Function

Specific disorder Rigidity Tremor Nasal Stiffness : None : None : None

Oculogyric Crisis : None Torticolis Others : None : None

Autoanamnesis, July 29th 2013: Question Assalamualaikum Pak... Answer Waalaikumsalam.. Interpretation Consciousness composmentis

Pak, awak pareso sambia maota lamak yo, pak ? Ambo dokter muda Atikah, iko kawan ambo Dokter Muda Annisa. Kalau namo apak sia, pak ?

Ambo ka dipareso... Jadih... Jadi adiak - adiak ko dokter muda. Namo ambo Monra

Cooperatif 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

Duo ba a induak nyo ko pak? Iyo, ambo lah duo kali manikah. Ciek anak dari bini patamo, ciek lai dari bini kaduo. Laki laki kaduonyo. Bapakai duo duo 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. 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 larang larang. Makonyo kini ambo tingga jo urang tuo ambo. Nyo tingga di Limo Puluah Kota, ambo di Payakumbuah jo anak kami. Jadi urang tuo apak yang mambaok apak ka siko? Indak. Uda jo adiak ambo. Personal Orientation is Good Situation Orientation is Good Place Orientation is Good Good Memory

Dek apo apak dibaok ka siko?

Ndak tau do. Tibo tibo se ambo dibaok ka siko..

Discriminative insight is distracted

Iyo ambo dek pai pai 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 pai pai se?

Io. Ado yang mambisiak an ka ambo, pai kalua. Pai kalua. Jalan taruih. Makonyo ambo pai.

Auditoric Hallucination ( + )

Nampak jo apak, padusi atau laki laki urangnyo? Ba a kok apak namuah se nyo kicek an?

Ndak nampak jo ambo do, tapi Delusion of Control ( + ) suaronyo suaro laki laki. 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?
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Auditoric Hallucination ( + )

Untuak a puaso tu? Ndak usah lai. Untuak apo lo tu.

Thought Insertion ( + )

Tu apo kicek, apak? Tapi kicek keluarga apak, apak ngicek ngicek surang, galak galak surang?

Ndak aso do ambo diam se nyo. Kalau ngicek ngicek 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 galak galak 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 mamacik macik ambo rasonyo. Tactil Hallucination ( + ) Dellusion of Passivity ( + ) Blocking and Inhibition ( + )

Ndak nampak tapi ado suaronyo yo pak yo?

Iyo. Tapi pernah waktu duo

Visual and Auditoric

bulan yang lalu, Ambo katamu Hallucination ( + ) Nabi Muhammad.

Ba a kok bisa batamu Nabi Muhammad apak? Nampak

Iyo. Mirip mirip Roma Irama tu lah. Beliau ngicek ka ambo, ko jalan nan luruih. Ko
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bantuak Nabi jo apak?

jalan nan salah. Ko pegangan iduik yang rancak. Turuik kan lah yang rancak.

Sajak bilo nampak nampak jo tadanga tadanga suaro tu? Waktu tu ado tabaun baun sesuatu ndak jo apak? Jadi manuruik apak, wajar ndak apak dibaok di rumah sakik jiwa ko? Kalau kini ndaka do tadanga danga, atau nampak, atau taraso raso yang patang tu lai pak? Patang tu ba a kok bisa sakik apak? Dek apo kiro kiro tu pak? Taragak bana, pak? Dek itu apak sadiah?

Sajak 2 bulan yang lalu tu lah.

Ndak ado do

Olfactoric Hallucination ( - )

Yo..., ambo malu. Manga patang galak galak surang, jalan ntah kama kama. Lah indak ado lai do

Discriminative Insight is good

Iyo, mungkin dek ambo banyak pikiran. Ambo taragak ndak ka babaliak jo bini ambo. Sadiah ndak lo do. Tapikia se untuak apo babini bapacar pacar banyak, ancak ciek se lai. Tapi kicek bini ambo nyo pikia pikia lu, alum bisa kini lai.

Stressor ( + )

Loh, banyak pacar apak tu?

Iyo ka patang patang tu. Tu patang ko ambo taragak jo

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bini se lai. Ndak berang bini apak, apak bapacar pacar? 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 kawan kawan nyo gai. Ambo bayia kan. Ambo supir angkot. Yo lai Banyak pemasukan apak jo nyupir tu? Supir apo apak? lah, balabiah labiah. Bisa manuruikkan kandak padusi padusi tu. Kadang pai jo kawan bagai, ambo traktir. Ambo ndak pilik pilik do. Dek itu apak banyak suko padusi ka apak? Iyo. Ambo bailmu. Sajak 2001. Tapi lah ambo buang sajak 2010. Takuik beko ado apo apo. 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? Kalau mandi, apak biasonyo lamo lamo, pak? Suko mambaka baka, mancaliak api gadang suko
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Symptoms of Manic

Delusion of greatness ( + )

Delusion of greatness ( + )

Delusion of greatness ( + )

Ndak punyo lai do. Indak. Biaso se nyo. Sabanta se Indak. Ndak pernah apak Pyromani ( - ) Hydromani ( - )

pak? Nah kini apo yang taraso dek apak? Sanang apo sadiah?

mambaka baka do. 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 Abulia ( - ) ambo yo ka nak babaliak jo bini ambo.

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? 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

Hehehe, yo ndak lai do..

Iyo alah dok. Alah tanang rasonyo kini. Lalok lamak, makan namuah. Samo samo dok.

Alloanamnesis was given by: Name/Age Address Telephone number Occupation : Mr. Eki Susandra/27 years old : Tanjung Haro Sikabu, Padang Panjang Luak, Payakumbuh. : 085263111760 : 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 ( 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. 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 ( 3 4 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 of

jaundice, cyanosis, and seizure. Childhood Adolescence : : growth and development according to his age. 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 ). 2 nd 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 appearance Consciousness/sens Attitude Motoric Facial expression Verbalization Physic contact Attention Initiative 2. Specific condition A. Affective 1. Affective condition 2. Emotional : a. Stability b. Control c. Echt/unecht d. Einfuhlung e. Deep/shallow f. Differentiation scale g. Emotional flow B. Intellectual condition of function a. Memory b. Concentration c. Orientation : : : good good good average normal : : : : : : : Stable Good echt Inadequat deep wide fast : eutym : : : : : : : : composmentis/good cooperative active rich speak clearly and fluently reacheable, fair, long enough Adequate Good

d. General and schooling knowledge : e. Discriminative insight f. Intelligence prediction : :

distracted average normal

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g. Discriminative judgment h. Intelectual deterioration

: :

distracted none

C. Sensation and perception abnormalities 1. Illusion 2. Hallucination Auditoric Visual Olfactory Tactile Gustatory D. Thought process condition 1. Speed of thought processs 2. Quality of thought process: a. Clear and sharp b. Circumstantial c. Incoherent d. Blocking e. Inhibition f. Flight of ideas g. Verbigeration h. Preservation 3. Thought condition a. Central pattern b. Phobia c. Obsession d. Delusion e. Suspicion f. Confabulation g. Repulsion h. Inferior feeling : : : : : : : : none none none present present none present none
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: none : : positive : positive : none : positive : none

fast

: : : : : : : :

clear and sharp enough none none positive positive none none none

i. Much/little j. Feeling guilty k. Hypochondria l. Others

: : : :

much none none none

E. Instinctual drive and behavior abnormalities a. Abulia b. Stupor c. Raptus/impulsivity d. Excitement state e. Sexual deviation f. Echopraxia g. Vagabondage h. Pyromania i. Mannerism j. Others F. Over anxiety G. Reality testing ability 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. : : : : : : : : : : : : none none none none none none present none none none none disturb in behavior, feeling and thinking

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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 tactil hallucination. d. Thought process condition: fast, clear and sharp enough, no central pattern, delusion present, much, coherent, presence of blocking and inhibition, e. Instinctual drive and behavior abnormalities: vagabondage present. f. Overt anxiety: none g. 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 since the illness
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 Social relationship ( visiting friends, mutual support, recitals ) couldnt be done since the illness Leisuring time ( travelling, watcing tv ) couldnt be done since the illness

MULTIPLE AXIS DIAGNOSIS I. II. III. IV. V. F.25.0 Schizoaffective Disorder Manic Episode No diagnosis No organic disorder Rejected by his wife for living together again GAF 41-50.

DIFFERENTIAL DIAGNOSIS I. II. F 30.2 Affective Disorder Manic Episode with Psycotic Symptoms 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 Functional Social : : : dubia at bonam dubia at bonam dubia at bonam
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