BST - Skizoafektif Tipe Manik

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Bed Side Teaching A 27 years old man was admitted to HB Sa’anin Hospital emergency unit on March 19 th 2014. He was accompanied by his family, with chief complaint: the patient was restless, irritable, angry, and hit his father 2 hours before admission. He also confessed that he heard voice telling him to do it. He slept 6 hours per days (more sleep in the afternoon) and eat 3 times per days with one portion of each. Patient was being like that for the second time and had been hospitalized in 2011. The restlessness of the patient is getting lesser after care. Patient identity: Name / Age : Mr. R / 27 years old MR : 01 17 xx Gender : Male Place and date of birth : Padang, March 25 th 2014 Marital status : Single Religion : Muslim Occupation / School : unemployed / not graduated from Electrical Technic Diploma in Andalas Polytechnic (until 3 rd semester) Citizen : Indonesian Tribe : Minangkabau Address : Complex Pesona Inanta E.5, Alai Parak Kopi, Padang 1

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BST - Skizoafektif Tipe Manik

Transcript of BST - Skizoafektif Tipe Manik

Bed Side Teaching

A 27 years old man was admitted to HB Saanin Hospital emergency unit on March 19th 2014. He was accompanied by his family, with chief complaint: the patient was restless, irritable, angry, and hit his father 2 hours before admission. He also confessed that he heard voice telling him to do it. He slept 6 hours per days (more sleep in the afternoon) and eat 3 times per days with one portion of each. Patient was being like that for the second time and had been hospitalized in 2011. The restlessness of the patient is getting lesser after care.Patient identity:

Name / Age:Mr. R / 27 years old

MR:01 17 xxGender:MalePlace and date of birth:Padang, March 25th 2014Marital status:SingleReligion:MuslimOccupation / School: unemployed / not graduated from Electrical Technic Diploma in

Andalas Polytechnic (until 3rd semester)Citizen:IndonesianTribe:MinangkabauAddress:Complex Pesona Inanta E.5, Alai Parak Kopi, PadangA. Internal Status

General appearance: Composmentis

Blood pressure: 110/80 mmHg

Pulse: palpable, regular, 82 times per minute,

Respiration: toracoabdominal, regular, 18 times per minute

Temperature: 36,80C

Body Shape: astenicusHeight: 170 cm

Weight: 50 kg

Cardiovascular system: Inspection: Ictus cordis cant be seen

Palpation: Ictus cordis was palpable, 1 finger medial away from LMCS ICS VPercusion: Cardiac edge : Upper edge ICS II, Right edge LSD, Left edge 1 finger medial from LMCS ICS VAuscultation : Regular rhythm, 82x per minute, no heart murmur.

Respiratory System :

Inspection: Symmetrical in static and dynamic position

Palpation: Fremitus left = right

Percusion: Sonor on left and right

Auscultation: Vesicular, no ronkhi (-/-), no wheezing (-/-)

Gastrointestinal system :

Inspection: Not distended

Palpation: Liver and spleen were not palpable

Percussion: Thympanic

Auscultation : Intestinal sound (+) normal

Specific disorder : No abnormality detected

B. Neurological Status

Cranial Nervous (five senses): Vision, smelling, hearing, tasting, and tactile are well

Meningeal Signs

: None

High Intracranial Pressure Signs : None

Eyes

Movement

: Free to all direction Perception

: No nystagmus, no diplopia

Pupil

: Round, isochoric Light Reflex

: +/+ Convergence Reaction

: Not examined Corneal reflex

: Not examined Ophthalmoscopy examination : Not examinedMotoric Tonus: Eutonus Coordination: Good

Turgor: Good

Strength: Good

555 555

555 555 Reflex: Physiologic : Patella Reflex (+/+)

Pathologic : Babinski Reflex (-/-)

Sensibility: No abnormality detectedVegetative Function: Good appetite, sleep well

Basic Function: Reading, writing, drawing, and calculating is well done.Specific disorder

Rigid: None

Oculogyric crisis: None Tremor : (+1) Torticollis: None Nasal stiffness: None

Others: NoneAllo AnamnesisName / Age: Mrs.L / 48 years oldGender: FemaleAddress: Complex Pesona Inanta E.5, Alai Parak Kopi, Padang

Phone number: 0852113327xxOccupation: Elementary school teacherEducation: Bachelors degreeRelationship: MotherI. Primary cause of hospitalization :

The patient was restless, irritable, angry, and hit his father 2 hours before admission. He also confessed that he heard voice telling him to do it. He slept 6 hours per days (more sleep in the afternoon) and eat 3 times per days with one portion of each. Patient was being like that for the second time and had been hospitalized in 2011. The restlessness of the patient is getting lesser after care.Patients complaint today: None

II. History of illness :

2008-2009 (the month was not remembered)The patient didnt continue his study since 2008 because he couldnt handle his tasks in college and had GPA (Grade Point Average) less than 2. He stopped in 3rd semester but he still took money from his parents for the next semester college payment. He spent the money for servicing his motorcycle and gave it to orphanages. His parent was angry when they knew about the fact, especially his father who always pushes him hard to study well and be successful person since he is a oldest child and the only one son in his family. Then, his parent never care anymore about what he was doing, but his mother still gave him money.One day he went to his hometown, Payakumbuh and got an accident. According to medical examination there was no serious injury, but after the accident he looked very shock, he didnt talk a word, couldnt sleep, and didnt want to eat. He can move his body spontaneously without a clear cause. He went to neurologist and got medicines, but according to the family, after some days there wasnt improvement of his condition and he became strange. He started to be irritable, easy to be angry, and like to kiss his mother. He also heard womans voice telling him to do things. Then the family took him to psychiatrist and got medicines.

Because the family couldnt see improvement of his condition, after 8 months consuming drugs from psychiatrist, they went for alternative treatment in their hometown that has boarding system. After some weeks, he was getting worse and the family decided took him home. after some weeks, slowly, he got better and can walk normally. 2011 (the month was not remembered)His father had a stroke attack, so he went to the hospital to see his father. In hospital, he hit his brother in law without reason so his family took him home. But he continued to be angry without reason and he wrecked household appliances. So his family took him to HB Saanin Hospital and he got hospitalized for a month. He went home with a quite condition. He controls his condition regularly and took medicine obediently. The medicines are:

Risperidone 2x1 tab @ 2 mg

Haloperidol 2x1 tab @ 1,5 mg

CPZ 1x1 tab @100 mg (his mother only gave CPZ when he started to talked

irrationally)THP 2x1 tab @ 2 mgAfter come home, he still doesnt have any job, he just spent the time at home, or went to his hometown or his friends home.

2014 (March)

He drank his father water and his father scolded him, but suddenly he became angry and hit his father. His father wanted to attack back, but other families tried to stop them. His father forced his mother to take him back to the hospital. Then his family brought him to the HB Saanin Hospital and he got hospitalized. His mother confessed that he drank a cup of coffee in the morning of that day outside her supervision.Premorbid history

Infant

: born spontaneously, birth was assisted by midwife, no history of jaundice, cyanosis, and seizure.Childhood: growth and development according to his age. He likes to play with friends.Teenage: growth and development according to his age. He likes to play with friends.

He was a very religious teenager and he liked to give a speech in the mosque.Adolescence: unemployed, still had a good relationship with his friends at schools and college.

Educational backgroundSD

: SD N 03 Alai Padang, graduated in 6 yearsSMP

: MTsN 1 Padang, graduated in 3 years

SMA

: SMKN 2 Padang, graduated in 3 years

College: Electrical Technic Diploma in Polytechnic Andalas Padang, not graduated. He didnt continue his study because he couldnt handle the tasks and GPA < 2. He

stopped in 3rd semesterIII. Occupation History

Unemployed IV. Marital History

Single V. Social Economic history

She lived with his father, mother, and 3 sisters in a permanent house. There is electricity and the water source is from PDAM. Monthly income of the family is more than enough for the patient.

IncomeFathers salary

Rp. 2.500.000,-

Mothers salary

Rp. 2.500.000,Sisters allocation

Rp. 1.000.000,-+

Rp.6.000.000,-

OutcomeFamily cost

Rp. 4.000.000,-

Water cost

Rp. 70.000,-

Electricity cost

Rp. 80.000,-+

Rp. 4.150.000,-

Remaining cost Rp. 1.850.000,-VI. Family history of illnessThere were no family members that has same symptoms like this or has mental disorder.

Graphic of illness

Autoanamnesis, March 21th 2014:QuestionsAnswersInterpretation

Assalamualaikum bang RobbiWaalaikum salamComposmentis

Cooperative

Bang, ambo Lani dokter muda disioko, buliah awak carito-carito jo abang kini bang?Buliah...

Lah bara umua abang bang?27Good time orientation

Tahun bara tu berarti bang?1987

Tanggal bara tu bang?25 Maret 1987

Oo

Lah bara hari disiko bang?Lah 4 hari

Sia yang baok kamari bang?KeluargaGood personal orientation

Sia se tu bang?Mama papa om adiak-adiak.

Lansuang di baok kamari abang?Ndak ka IGD di muko dulu. Hari ko baru ka Flamboyan ko.Good place orientation

Baa caritonyo bang, kok dibaok abang kamari samo keluarga?(senyum lebar, kontak mata ada, tapi tidak menjawab)Hemmung

Bang? Baa bang? Baa kok dibaok kamari?Bacakak samo papa

Bacakak? Baa caritonyo tu bang(lama menjawab)

Manga abang waktu tu?Ndak nio makan

Jam bara memangnyo kejadiannyo bang?Maghrib

Alun makan siang abang lai do?(tertawa) alun

Tu baa lai bang?(tersenyum senang)

Bang? Iyo tu berang papa,bangih se caliaknyo.

Tu kanai berang abang?Mama nelfon omLack of attention

Manga nelfon om bang?Baok abang ka rumah sakik

Itu se nyo bang? Abang ndak ado berang ka papa?NdakConfabulation

Iyo bana tu bang? Tu manga abang dek itu se di baok ka rumah sakik?Iyo. Dek bacakak.Disturbed discriminative insight

Bacakak baa ko bang?Papa berang

Abang berang lo?Ndak

Bacakak muluik?Iyo

Bacakak muluik se nyo bang? Iyo

Yang lain? (tertawa)

Ado abang kayak malokok papa abang gai nak?Ndak

Papa abang ado malokok abang?Iyo

Tu diam se abang?Iyo

Jadi baa kok abang yang di baok ka rumah sakik?DisuntikDisturbed discriminative judgement

Supayo disuntik?Iyo

Papa abang ndak disuntik? Abang yang disuntik?

Abang tu yang salah?(tertawa)

Baa kok abang yng disuntik?.(tertawa)

Baa bang?Abang sakik.

Abang alah duo kali disiko ma. Di Flamboyan ko.Lack of memory

Iyo bang? Bilo yang pertamo?Tahun 2011

Manga waktu tu tu bang, kok dirawat abang?(tertawa)

Ndak takana

Kan baru tu bang kana-kana lah dulu bang(tertawa)

Baa caritonyo waktu tu tu bang?(tidak menjawab)

Kini apo yang taraso bang?(tersenyum lebar)Inappropriate affect

Lai sanang disiko bang? Sanang hati abang bantuaknyo ha.Indak (tapi tersenyum senang)

Lai banyak kawan disiko?Indak (masih tersenyum senang)

Waktu sakik tu baa rasonyo bang?(tertawa)

Ndak tau

Berang bana abang rasonyo?(tertawa)

Ndak tau

Kalau sadang sakik ko lai abang tadanga suaro-suaro bang?AdoAuditoric halutination

Suaro apo tu bang?Nyo mangecek ka abang. Suaro apo tu?

Baa suaronyo bang? Suaro abang?Ndak suaro padusi

Mangeceknyo ka abangIyo.

Lai sabana tu bang? Ka abang se nyo mangecek nyo bang?Yo bana.

Ndak tau

Apo yang nyo kicek an emangnyo bang?Karajoanlah karajoanlahDelusion of influence

Tu abang karajoan?Indak lah

Nampak urang nyo bang?

Atau ado Nampak bayang-bayang?Ndak

Mencium bau-bau aneh bang?Ndak ado

Atau ado nyo kaca-kaca abang?Ndak

Haa tu nyo ha.Auditoric halutination

Apo tu bang?Ado tadanga?

Ndak bang apo katonyo bang?indak

indak katonyo bang/Iyo. Ndak tadanga?

Ndak bang. Ndak ado apo-apo do. Sabana tu bang?Iyo. Ndak tadanga do yo?

Ndak ado tadanga do bang.(tersenyum senang)

Ado yang taraso baulang jadinyo di kapalo abang yang dikecekan tu bang?Iyo. Baulang-ulang rasonyo di kapalo ko.Thought eco

Bagema rasonyo?Iyo

Kalau pikiran abang dibaco urang lain rasonyo ado bang?Ndak

Atau abang bisa mambaco pikiran urang?Ndak

Jadi kini apo yang taraso bang?(mengangkat bahu)

Ndak tau

(senyum-senyum)Inappropriate affect

Ndak nio pulang do?Nio sobok papa

Baa tu?Jalan-jalan

Kama jalan-jalan bang?Ka pantai

Ka kampuang abangIncoherent

Kampuang abang di pariaman?Di payakumbuah

Kalau kalua dari siko apo rencana bang?(tertawa)

Lah karajo abang?Alah

Dima bang?Di PLNDelusion of grandeur

Apo tu bang karajonyo?Listrik. Masang instalasi lisrik rumah-rumah ko ha

Oo lah lamo abang karajo disitu?Alah. Lah 3 tahun.

Tapi abang sakik tahun 2011., masih karajo disitu? Iyo. Tahunan.

Tamat apo abang dulu bang?SMTI

Sekolah Menengah Teknik Industri?Iyo

Tamat 3 tahun bang?Iyo

Sudah tu langsuang karajo?Ndak kuliah dulu

Oo dima kuliah bang?Di poli

Politeknik Unand?Iyo

Jurusan apo bang?Sastra

Ha. Ma ado jurusan sastra bang?Ado

Tapi abang dari SMTI. Ambiak sastra abang?Iyo

Sastra apo bang? Sastrawan

Ma ado jurusan sastrawan bangAdo

Yang ado tu sastra Indonesia, sastra InggrisIndonesia

Sastrawan Indonesia

Bara tahun tu bang?D4

Iyo, bara tahun tu bang?4 tahun

Sudah tu karajo abang di PLN?Iyo

Bisa yo bang? Abang tapi sastrawan?Bisa. Awak sewo.

Sewo ko baa bang?Tahunan di sewo.

Pulang dari siko abang nio karajo baliak disinan?Iyo

Abang bilo rencana pulang emangnyo?Ndak tau

(tersenyum)Inappropriate affect

Sakik apo abang kini ko?Ndak tau

Makan ubek abang?Iyo. Makan ubek taruih.

Untuak apo tu bang makan ubek?(tertawa)

Jadi abang ndak nio pulang?Di rawat dulu

Baa kok abang dirawat?Supayo sehat

Bara lamo abang ka dirawat?Sabulan

Sabulan? Ndak nio pulang abang?Ndak baa bia sehat dulu.

Jadi apo sakik abang kini ko?(senyum-senyum)

Kini ndak ado yang taraso? Sedih? Sanang? Ndak ado (tersenyum lebar)

Yo lah mokasi yo bang. Istirahatlah abang lai.

AssalamualaikumWaalaikum salam.

Explanation and Conclusion of Psychiatric ExaminationExamination was done on March 21st, 6.00 p.m.1. General appearance

Consciousness/sensorial:composmentis/good

Attitude:cooperative

Motoric:active

Facial expression:richVerbalization:speak clearlyPsychical contact:could be done / proper enough / long enough

Attention:good enoughInitiative:good enoughPatientss writing and drawing is present.

2. Specific condition

A. Affective

1. Affective condition : inappropriate2. Emotional :

a. Stability:stable

b. Control:goodc. Echt/unecht:echt

d. Einfuhlung:inadequate e. Deep/shallow:shallowf. Differentiation scale:narrow

g. Emotional flow:fastB. Intellectual condition of function

a. Memory:lessb. Concentration:difficultc. Orientation:time, personal, and place orientations are goodd. General knowledge : hard to predicte. Intelligence prediction:average

f. Discriminative insight:disturbedg. Discriminative judgment:disturbedh. Intellectual decreasing: noneC. Sensation and perception abnormalities

1. Illusion: none

2. Hallucination:

Acoustic:present, the sound of a woman telling him to do thingsVisual:noneOlfactory: none Tactile: none

Gustatory: noneD. Thought process condition

1. Speed of thought processs:slow2. Quality of thought process:

a. Clearness and sharpness:not clear enough and not sharp enough

b. Circumstantial:nonec. Incoherent:noned. Sperrung:none

e. Hemmung:presentf. Flight of ideas:none

g. Verbigeration:none

h. Preservation:none

3. Thought condition

a. Central pattern:noneb. Phobia:none

c. Obsession:noned. Suspicion:nonee. Delusion:delusion of influence, delusion of

grandeurf. Confabulation:presentg. Dominance, animosity:none

h. Inferior feeling:nonei. Much / little:littlej. Guilty feeling:nonek. Hypochondria:none

l. Others:none

E. Instinctual impulse and behavior abnormalities

a. Abulia:presentb. Stupor:none

c. Raptus/impulsivity:presented in 3 days ago, subsided since a

day agod. Excitement state:nonee. Sexual deviation:none

f. Echopraxia:none

g. Vagabondage:noneh. Pyromania:nonei. Mannerism: none

j. Others:noneF. Over anxiety:noneG. Reality testing ability:behavior, thought, feeling are disturbedmultiple axis Resume

Axis I. Clinical SyndromeThe patient was restless, irritable, angry, and hit his father 2 hours before admission. He also confessed that he heard voice telling him to do it. He slept 6 hours per days (more sleep in the afternoon) and eat 3 times per days with one portion of each. Patient was being like that for the second time and had been hospitalized in 2011. The restlessness of the patient is getting lesser after care.

General Appeareance: composmentis cooperative, good sensorium, initiative (-), cooperative, active motoric, rich facial expression, lack of initiative, lack of attention, talk clearly, physical contact can be done, proper enough and long enough.Specific condition:

a. Affective condition: inappropriate, stable, control is good, echt, inadequat, shallow, narrow, fast.b. Intellectual condition and function: memory is less, concentration is difficult, discriminative insight disturbed, discriminative judgment is disturbed, orientation is good, intelligence prediction is averagec. Sensation and perception abnormalities: accoustic halutination d. Thought process condition: slow, not clear and not sharp enough, incoherent, hemmung, delusion of influence, delusion of grandeur, confabulatione. Instinctual drive and behavior abnormalities: abulia, raptus/impulsivity presented in 3 days ago, subsided since a day agof. Overt anxiety: noneg. Reality testing ability: behavior, feeling and thinking are disturbedAxis II : Personality Disorder and Mental Retardation Disorders

Personality: outgoing, has friendsMental retardation: noneAxis III : General Medical Condition

Head traumas history was absent No history of malaria, typhoid, or brain and neurological diseaseAxis IV : Phsychosocial Stressor and Environment His father always pushes him hard to study well and be a successful person and his father also easy to be angry to him

He couldnt continue his study because he couldnt handle tasks and his GPA < 2

Being jobless since he stopped to study

Axis V: Global Assessment of Function

Daily activity couldnt be done since 3 days ago Social relationship couldnt be done since 3 days ago Spending time with watching TV, recreation, couldnt be done since 3 days agoMULTIPLE AXIS DIAGNOSIS

I. F 25.0 Schizoaffective disorder, manic typeII. No diagnosisIII. No diagnosisIV. Being pushed hard and rudely by his father, he couldnt continue his study and being joblessV. GAF 51-60DIFFERENTIAL DIAGNOSISI. F 20.1 Schizophrenia hebephrenicII. F 31.2 Bipolar affective disorder,current episode manic with psychotic symptomsIII. F 20.3 Undifferentiated schizophreniaTHERAPY Risperidon 2 x 2 mg Diazepam 1 x 2 mgSUGGESTION FOR THERAPY

CPZ 2 x 100 mg For long term therapy: Injection of Haldol decanoas 50 mg IM, once a month. Psychotherapy to the patient and family.PROGNOSIS

PointGoodNot good

OnsetAdult

DiagnosisSchizoaffective disorder, manic type

Family SupportNot good enough

Marital statusSingle

EconomicMiddle higher class

MedicineRegularly

Faktor pencetusClear

GeneticNone

Others diseaseNone

Clinical:dubia at malamFunctional:dubia at malamSocial:dubia at bonamStopped his study

His parents were angry

His father irritate his feeling

His father got a stroke attack

(3) 2014

2011

2008-2009

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