Case Report Session

SCHIZOAFFECTIVE DISORDER, MANIC TYPE

By:
Dini Aini Putri

P. 1733 B

Rostika Ayu

P. 1730 B

Preceptor:
Dr. Yaslinda Yaunin, Sp.KJ

PSYCHIATRIC DEPARTMENT
FACULTY OF MEDICINE UNIVERSITY OF ANDALAS
RSUP DR M DJAMIL PADANG
2015

PSYCHIATRIC PATIENTS STATUS

A female patient, 29 years old, was admitted to HB. Saanin Mental Hospital Padang on
28 August 2010. Patient was admitted from emergency room accompanied by family with the
complain: Agitative, ruminative, destroy home tools, no take a bath in month, defecate anywhere,
silence, sometimes talk to herself, hitting her mother, sick since 5 years ago. This is her second
time being hospitalized.
th

Patients Identity

Name

: Imelda Satrisna/ Upik

Sex

: Female

Birth date/age : February,24th, 1981 (29 years old)

Birth place

: Pakandangan

Occupation/ Education : Unoccupied / finished 3rd grade in high school of nurse (SPK)
Marital status : Not married
Address

: Ringan-ringan Pakandangan, Enam Lingkung Padang Pariaman

Religion

: Islam

Civilian

: Indonesia

Ethnic

: Minangkabau

Internal Status
General appearance

: Compos mentis

Body space

: Astenicus

Blood pressure

: 110 /70 mmHg

Pulse

: 80 x/minute

Breath

: 22 x/minute

Height

: 155 cm

Weight

: 68 kg

Temperature

: 37 C

Respiratory system

: vesicular, rhonci (-/-), wheezing (-/-)

Cardiovascular system: regular, murmur (-)

Gastrointestinal system : Normal
Spesific disorder

: None

Neurological Status
Meningeal stimulation sign

: neck stiffness (-)

Increased intracranial pressure sign : projectile vomit (-), progressive headache (-)
Eyes
Movement

: move freely to any direction, nystagmus (-)

Pupil

: round shape, isochoric,

diameter 2mm/2mm

Light reaction

: positive / positive

Convergence reacton

: positive / positive

Cornea reaction

; not done

Opthalimoscope examination : not done

Motorist
Tonus

: eutonus

Coordination

: good

Turgor

: good

Power

555
555

555
555

Reflex

:
Physiology (patella) : positive/positive, normal
Pathology (Grasp)
Sensibility

: glabella (-), graps (-)

: smooth and rough are good

Vegetative nerve composition: sleep, wake up, and eat function are good
Specific disorder

: tremor (-), rigidity (-)

Laboratory examination on 16 th September, 2010

Haemoglobin

: 11.4 g%

Leucocytes

: 7800/mm3

Different count

: 0/0/1/69/25/5

Auto Anamnesa

Questions

Answer

Assalamualaikum
Ambo adi, iko teman ambo robby,,

Waalaikumsalam
Imel

namo uni sia?

Bisa ngecek-ngecek wak sabanta

Iyo

ni?
Lagi manga ko ni?
Apo taraso kini ni?
Dima kampuang?
Apo taraso kini ni?
Trauma dek a ni?

Ndak ado
Takana kampuang
Ringan-ringan pakandangan
Awak trauma.
Awak karajo di Malaysia, awak
tki, karajo di marakik bahanbahan pasawek.

Trauma manga?

Awak takuik dek garo-garo

salah marakik bahan pasawat.
tu bahan yang awak salah buek

Interpretation

tu tetap di masuak an. Ndak

Feeling guilty

lamo abis tu pesawat tu jatuah.

Ado uni mancaliak sesautu?

Lai, ado urang cino, laki-laki.

Visual halusination

Sia tu? Tantu dek uni?

ado mandanga sesuatu yang

Lai, ado nyo dimajalah.

Ado, wak mandanga pesawat

illusion
Auditoric halusination

asiang?

manggas diateh kapalo wak, tu

tahubuang se jo pilotnyo wak.

Eh, uni lai ado maraso kani pacik

Lai tangan wak kanai pacik jo

jo urang?

urang cino tu. (taktil

Ado Maraso sesuatu asiang taraso

halusination)
Lai, ado taraso babi, ula wak

dimuluik ndak?
Wajar ibuk di rawek disiko?

raso.
Indak, wak wajarnyo dipanjaro

Dek a tu?

Io wak salah mambuek bahan-

Uni tau manga di bawo kasiko?

Sia yang mambawo uni kamari?
Ooo.. yauda lah ni, waktunyo

bahan pesawat.
Karena wak trauma.
Pak taufik.
Ya.

istirahat.
Makasi banyak ya ni, jangan lupa

ya

minum obatnya biar capek cegak.

assalamualaikum

Walaikumsalam

Allo anamnesa being taken from

Tactil halusination

Gustatoric halusination

Name / age

:Sri Wahyuni, 35 years old

Sex

: Female

Address

: Komplek Perumahan RSJ HB Saanin. Padang

Phone

: 081363277515

Occupation

: Nurse

Relationship with the patients: nephew

Allo anamnesa :
1. Main reason hospitalization
Raging, Agitating, destroying home tools, no take a bath in month, indiscrimannet
defecate, Hitting her parent, patient second time being hospitalized
2. Present complain of patient
There is no complain
3. History of illness
2004 (forget about month)
Patient went to malaysia (TKI), work at air plane production. Just three months she
back to Indonesia because she is sick.
2005 (forget about month)
Her father married again, it was made her so desperated and refused the condition.
2005 - 2009
Patient was admitted from emergency room HB Saanin hospital accompanied by
family with the complain: Agitative, ruminative, destroy home tools, no take a bath in
a month, defecate anywhere, silence, sometimes talk to himself, hitting her mother.
February 2009
Patient was being controlled in M. Djamil Padang and back in stable condition after
took serenace injection every month.
August 2010
Patient was being hospitalized in HB. Saanin because the condition was getting
worse, she didnt get the injection of modecate again since january 2010.
4. Premorbid history
Infant
: Born spontaneously, assited by village midwife, no history of
jaundice, cyanosis, or seizures.
Childhood
: Growth and development suitable for her age.
Adolescence
: Secretive and less friends.
5. Educational background
Elementary school : Finished 6 th grade in SDN 1 Pakandangan
Junior High school : Finished 3 rd grade in SLTPN 1 Pakandangan,
Senior High school : finished 3rd grade in high school of nurse (SPK

6. Social economy background

Live with his parents, brother and sister. Father work as lumberjack in furniture
production.
Income monthly

Rp 1.500.000

Outcome monthly

Foods
Pocket money for 6 childs
Electric n water supply
Subtotal

Rp. 400.000,Rp. 1.000.000,Rp. 100.000,Rp.1.500.000,-

Total income
Rp. 1.500.000,Total outcome
Rp. 1.500.000,Saving
: none
The patient is not satisfied with this economic condition.
Lived in permanent house, electricity and water present. Televison and motorcycle
present.
7. Marriage background
Not married
8. Family history of illness

Patient

There is no family member with same disease

9. Graphic of illness
symptom began to appear

2004

2005

refuse medication, patient getting worse, hit his father

2009

2010

Summary of Phsyciatric Examination

1. General Appereance
Counciousness

: compos mentis

Attitude

: cooperative

Motoric

: hipoactive

Facial expression

: poor

Verbalization

: can talk, clear, and fluent

Phsycic contact

: can be done, appropriate, pretty long period

Attention

: good

Initiative

: less

2. Specific Condition
A. Affective
1. Affective condition
2. Emotional :
a. Stabitily
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
d. Knowledge
e. Discriminative insight
f. Intelligence prediction
g. Discriminative judgment

: dull, depressed
: stable
: controlled
: echt
: adecuate
: shallow
: narrow
: fast
: good
: good
: good
: less
: disturb
: normal
: disturb

C. Sensation and perception abnormalities

1. Illusion
: present Chinese people see in magazine
2. Hallucination
:
Acoustic
: present, heard plane

Visual
: present, see chinas
Olfactoris
: none
Tactil
: present, the chinas touch her
Gustation
: present, savor pig, snake
D. Trought process condition
1. Speed of thought process
: slow
2. Quality of thought process
a. Clear and sharp
: less clear less sharp
b. Sircumstansial
: none
c. Incoherent
: none
d. Blocking
: none
e. Resistance
: none
f. Flight of ideas
: none
g. Verbigeration
: none
h. Perservation
: none
3. Thought condition
a. Central pattern
: none
b. Phobia
: present, plane and chinese
c. Obsession
: none
d. Delusion
: none
e. Suspicion
: none
f. Confabulation
: none
g. Repultion
: none
h. Confabulation
: none
i. Inferior feeling
: present
j. Much/little
: little
k. Feeling guilty
: present, aeroplane because she had made a
foul when making an aeroplane tools.
l. Hypochondria
: none
m. Others
: none
E. Instingtual drive and behavior abnormalities
a. Abulia
: none
b. Stupor
: none
c. Raptus/impulsivity : none
d. Excitement state
: none
e. Sexual deviation
: none
f. Echopraxia
: none
g. Vagabondage
: none
h. Pyromani
: none
i. Mannerism
: none
j. Others
: none
F. Over anxiety
: present
G. Reality testing ability
: disturbed in behavior, feeling and thinking.

RESUME MULTIPLE AXIS

Axis I. Clinical syndrome
Agitative, ruminative, destroy home tools, no take a bath in month, defecate anywhere, silence,
sometimes talk to herself, hitting her mother
General condition : compos mentis, cooperative, initiative less, hypoactive, motoric passive,
poor facial expression, verbalization can talk, clear, and fluent, phsycic contact present,
appropriate, briefly.
Specific condition :
a. Affective condition : hipothymia, stable, echt, adequate, shallow, slow.
b. Intellectual condition of function : good memory, good concentration, orientation good,
knowledge less, discriminative insight disturb, normal inteligency, discriminative
judgement disturb.
c. Sensation and perception abnormalities : acoustic, visual, tactil and gustatoric
hallucination.
d. Tought process condition : slow, less clear less sharp, sircumstansial, resistance,
suspicion, inferior feeling present, feeling guilty.
e. Instingtual drive and behavior abnormalities : none
f. Over anxiety
: present
g. Reality testing ability
: disturbed in behavior, feeling and thinking
Axis II. Personal disorder and mental retardation disorder
-

Personality disorder : none

Mental disorder : none

Axis III. General medic condition

Didnt have history of trauma capitis, tifus abdominalis or malaria which need
hospitalization. Lab result for hemoglobin : 11,4 gr/dl
Axis IV. Psychosocial stressor and environment
-

Economic problem and family problem

Axis V. Global assessment functional

-

Social : visit friends, mutual assistance, pray and attend invitation couldnt be done since
30 days ago.
Daily Activity : teaching pupils, sweeping, mopping and doing laundry could be done.
Freetime activity : watching television

Multiple Axis diagnosis

I. F.20.0 Skizofrenia paranoid
II. no diagnosis
III. no diagnosis
IV. Economic and family related problems
V. GAF 50-41
Differential diagnosis
I. F31.5 Bipolar Affective Disorder, Major Depression Episode with Psychotic
II. F25.1 Skizoaffective depressive type

Therapy
-

Trifluoperazine 2 x 1 tablet @ 5 mg
Amitriphtylin 2 x 1 tablet @ 25 mg
Chlorpromazin 1 x 1 tablet @100 mg

Prognosis
Clinical

: dubia ad bonam

Functional

: dubia ad bonam

Social

: dubia ad bonam