WULAN PRISILLA P.1512AMRINA RASYADA P.1513

Preseptor:Dr. Yaslinda Yaunin, Sp.KJ(K)

Bed side teaching

A woman, 62 years old entered to General Hospital M. Djamil Padang Patient entered on December 9th, 2014, accompanied by her son in law.

Chief complainThe patient raged violently, took the fire,

held the knife, talked alone, laughed alone, danced alone, walked alone without direction.

Recent historyThe patient raged violently, took the fire, held the

knife, talked alone, laughed alone, danced alone, walked alone without direction since one day before admission.

One month before admission, patient came to Medan to visit her youngest brother. There, the patient got hard pressure from her brother. When the patient wish to came back to Batusangkar, the brother refused her wish. Her brother have rough personality. So, the patient had pressure. She sat alone in the traffic light in Medan. She had pee in the people’s home. Then, her brother took the patient to Batusangkar.

Recent historyArrived at home in Batusangkar, the patient raged

violently, took the fire, held the knife, talked alone, laughed alone, danced alone, walked alone without direction. Then, the son in law took the patient to the general hospital M. Djamil, Padang.

Patient lives alone since 2 years ago. Previously, she lived with her daughter and son in law and 3 grandsons. The patient decided to live alone because she felt like to be alone and didn’t like to be bridled. The daughter and family visited the patient once a week; the distance is about one km.

On 2010, the patient had suspicious to her neighbors. She felt that the neighbors liked to talk about her, competed her and others, ordered her anything.

Previous historyPsychiatry disorder history

On 2013, the patient had psychiatry disorder like talked alone, walked alone without direction, and danced alone. Then, her daughter and son in law took the patient to indigenous medical practitioner. The practitioner didn’t give some traditional medicine, but only gave some magic formula to patient. The patient got better.

Medical disorder historyThe patient didn’t have some medical history disease,

surgery history, accident history, neurologic disorder, tumor, convulsion, consciousness disorder, HIV, etc.

Alcohol and addictive substance using historyThere is no history of using nicotine, alcohol,

morphine, etc.

Private historyPrenatal/ Perinatal period

Patient was born as the 4th child of 6 siblings. In the pregnancy, patient’s mother had no disease and no consume of medicine. Patient was born on time and norm weight. The pregnancy was helped by indigenous medical practitioner and cried.

Early pediatric period (0-3 years)Patient grew and developed healthy like others.

Middle pediatric period (3-11 years)Patient grew and developed healthy like others, had

friends.Late pediatric period and adolescence period

Patient grew and developed healthy like others, had friends.

Private historyAdult period

Education history The patient got education until 2nd grade of elementary school.

Job history The patient is a vegetable seller. There is no conflict among sellers.

Marriage history The patient had two times of marriage. First marriage with first husband

was divorced because of dishonesty. The husband was back to his first wife. Then, the patient married for the second time, got one daughter. They divorced on 1978 because patient felt that the second husband was lazy, less in attention and didn’t have hard work. 2 years ago, her ex-second husband died, she didn’t depress.

Religion history The patient is Muslim. She believes to god and prays 5 times a day. She

read Quran. There is no conflict to other faith. Psychosexual history

There is no history of psychosexual history. Social activity

The patient and neighbor had conflict. The patient felt that everyone was talking about her.

Violation of law history There is no history of violation of law.

Family history

Family historyPatient’s eldest sister had psychiatric

disorder. Her sister liked to be alone, keep silent, and not interested in talking each other. According to the family, it happened because she got the magic formula after eating food in a meeting. There is no medical record history including admission and control to doctor.

Recent life situationThe patient lives alone in the house since 2

years ago. Previously, she lived with her daughter, son in law and 3 grandsons. Recently, they usually visit the patient once a week. Their communication is good. Patient lives in an old house, like a cottage. There is no vehicle, there is electricity, and the water is from PDAM. The salary got from herself as vegetable seller and youngest brother from Medan as rice seller. Family didn’t know the number she got every month. The salary is enough for her daily needs.

Family’s perception and hopeFamily wanted the patient get well soon.

Patient’s perception and hopeThe patient needed to come home. She

wanted to meet her family especially her grandsons.

Internal StatusGeneral Condition: Moderate illAwareness: ComposmentisBlood pressure: 130/90 mmHgPulse: regular, strong lift, frequency 83

times/minuteRespiration: moderate, torachoabdominal,

frequency 20 times/minuteTemperature: AfebrilHeight: 157 cmWeight: 58 kgNutritional status: well

Cardiovascular systemInspection :Ictus cordis not visiblePalpation :Ictus palpable around one finger medial to left

midclavicular line, 5th intercostal spacePercussion :Up: 2nd intercostal space, left: one finger medial to left

midclavicular line, right: dextra sternalis lineAuscultation: normal and regular heart sound, murmurs absentSistem RespiratorikInspection :Simetric statically and dinamicallyPalpation :Fremitus similar between left and right chestPercusion :Sonor all over the thoraxAuscultation: Vesicular breath sound present, ronchi absent,

wheezing absentSpecific abnormalities :-

Neurologic StatusGCS : E4M6V5

Meningeal Sign : absentExtrapiramidal signHand tremor : absentAkatisia : absentBradikinesia : absentWay of stepping: normalBalance : non disturbedRigiditas : absent

Motoric : freely in any direction  Sensorik : well propioseptif and

exteroseptifRefleks : Phisiologic reflex (+),

phatologic reflex (-)

Pertanyaan Jawaban Interpretasi

Siang buk. Saya dokter muda Wulan dan ini dokter muda Rina. Buliah kami tanyo ibuk subanta?

Iyo, Buliah nak

Compos mentisCooperative

Sia namo ibuk? Baidar Personal orientation intact

Bara umua ibuk kini? 54 tahun

Time orientation disturbed

Tahun bara ibuk lahir?

Tahun 57

Hari apo memangnyo kini tuh buk?

Hari Selasa

Pertanyaan Jawaban InterpretasiBaa kok ibuk dibaok kamari?

Ndak tau doh nak, minantu ibuk ngajak ka tampek si Nur. Siap itu ibuk dikabek. Pak dokter mambaok kamari. Subang, hape samo barang ibuk diambiaknyo dek minantu. Kalau ado inyo pasti ilang barang ibuk.

Discriminative insight disturbed

Situational orientation intact

Suspicious (+)

Waktu itu baa kok dikabek ibuk?

Ndak tau ibuk doh

Manuruik ibuk, patuik ndak ibuk kanai kabek?

Ndak ndak. Ibuk ndak malawan doh. Ibuk manangih ajo dek kanai kabek.

Discriminative judgment disturbed

Pertanyaan Jawaban InterpretasiManuruik ibuk, patuik ndak ibuk kanai kabek?

Ndak ndak. Ibuk ndak malawan doh. Ibuk manangih ajo dek kanai kabek.

Discriminative judgment disturbed

Ibuk tau kini sadang dima?

Dirumah sakik Padang

Spatial orientation intact

Kalau dari rumah ibuk ka Padang, awak lewat ma buk?

Lewat Padang Panjang

Jadi apo nan taraso di ibuk kini?

Ndak ado

Sabalumnyo, ibuk ado maraso dibisiakkan sesuatu?

Ndak nak Acustic halutination (-)

Kalau raso diraba-raba atau dipegang?

Ndak ado doh nak Tactil halutination (-)

Kalau maliek bayang-bayangan?

Ndak ado Visual halutination (-)

Pertanyaan Jawaban InterpretasiAcok ibuk membau-bau sesuatu yang busuak tapi ndak jaleh dari ma asalnyo?

Ndak juo doh nak Olfactory halutination (-)

Ibuk ado maraso dandam atau banci ka urang

Indak pernah, tapi iyo tetangga ibuk suka maotaan ibuk Animosity/revenge (+)

Tentang apo ibuk diotaannyo?

Pokoknyo tetangga tuh sirik ka ibuk

Ibuk pernah maraso ndak baguno?

Ndak pernah nak Inferior feeling (-)

Kalau kalua dari siko ibuk nio manga?

Ndak ado, ibuk nio katamu cucu

Abulia (-)

Apak masih ado buk? Nyo alah maningga. Laki ibuk. Pertamo pajudi. Kaduo pamain padusi.

Animosity/revenge (+)

Pertanyaan Jawaban InterpretasiBara urang anak ibuk dari suami tadi?

Suami pertamo ndak dapek anak. Kaduo ado anak surang

Personal orientation intact

Jadi apak masih ado kini buk?

Alah maningga nak. Tapi alah lamo pisah samo ibuk

Maaf buk, kalau jo suami pertamo pisahnyo karno apo buk?

Nyo selingkuh nak

Iyolah buk. Makasih banyak waktunyo buk. Kami pamit dulu.

Iyo nak

General Conditiona. Awareness: Composmentis Attention :

intactb. Attitude : Cooperative Inisiative :

presentc. Motoric behaviour: actived. Facial expression: riche. Speech and verbal: speak fluently and clearlyf. Physical contact : can be done, natural,

and long-time

Spesific conditionA. Natural State of Feeling 1. Afective condition : euthym2. Emotion Living a. Stability : stabile b. Control : controlled c. ech – unecht : echt d. einfuhlung ( invoelaarhaid ) : inadequate e. deep-shallow : shallow f. differentiation scale : narrow g. emotion flow : slow

Intelectual FunnctionMemory (amnesia) : lessConcentration : wellOrientation ( time, spatial, personal, situation): time orientation

disturbedgeneral knowledge : lessdiscriminative insight : disturbedalleged level of intelegency : in normal

avaragediscriminative judgment : disturbedintelectual deterioration : no

Perseption and sensation anomalya.illution : absentb.halutination - acustic : absent

- visual : absent - olfatorik : absent - tactil : absent

Way of Thingking 1. Psikomobilitas: slow2. Thingking processclear and sharp : clear but not sharpSirkumstansial: absentInkoherrent: absentSperrung : presentHemmung : presentFlight of ideas : absentVerbigerasi Persevarative ( Persevaratich ):

absent

Contents Central pattern : absentPhobia : absentObsess : absentDellusion : absentSuspicion : present (to her son in-law) Confabulation : absentAnimosity/revenge : presentInferior feeling : absentMuch/less : muchGuilty feeling : absentHippochondria : absent

Instinctual impulse disordersAbulia : absentStupor : absentRaptus / impulsivitas : absentexcitement state : absentsexual deviation : absentEchophraxia : absentVagabondage : absentPiromani : absentMannerisme : absent

Overt anxiety : absentRelation to reality : undisrupted

Multiaxial EvaluationAxis I. Clinical SyndromeRaging violently, taking the fire, holding the

knife, talking alone, laughing alone, dancing alone, walking alone without direction.

General condition: cooperative, active, speaking fluently and clearly, psychic contact can be done for long duration of time, attention intact.

Specific conditionNatural state of feeling : euthym, stabile, good

controlling, echt, inadequate einfuhlung, shallow, narrow differentiation scale, slow emotion flow

Intellectual condition : memorizing abililty intact, concentrarion ability intact, orientation intact, discriminative disturbed, discriminative judgment disturbed, intelligence level normal, intellectual regression absent

Sensation and perception disorder: absent of illusion and hallucination.

Process of Thinking: slow, clear but not sharp, circumstancial absent, incoherrent absent, Sperrung present, Hemmung present, flight of ideas absent, verbigeration absent, phobia absent, delusion absent, suspicion present, confabulation absent, animosity and revenge present, inferior feeling absent, guilty feeling absent, hypochondria absent.

Instinctual encouragement: abulia absent, stupor absent, raptus absent, excitement state absent, sexual deviation absent, echophraxia absent, vagabondage absent, pyromania absent, mannerisme absent.

Anxiety: absentRelation to reality: undisrupted

Axis II. Personality disorder and mental retardation

No diagnosisAxis III. General Medical ConditionNo history of head trauma, malaria, typhoid,

and other disease which needs hospitalization. No history of alcohol and drugs consumption.

Axis IV. Psychosocial and environmentDivorcedLess of attention

Axis V. Global Assessment of FunctioningModerate symptomp and disabilities

MULTIAXIAL DIAGNOSISI.F. 25.0 Schizoaffective Disorder with Manic

TypeII.NoneIII.NoneIV.DivorcedV.GAF 60-51

DIFFERENTIAL DIAGNOSIS1. F. 20.0 Paranoid Scyzophrenia2. F. 20.3 Undifferentiated Scyzophrenia

THERAPYPharmacotherapy :Haloperidol 5mg 3x1 tabletVit.B 50mg 3x1 tabletVit.C 50mg 3x1 tablet

Psychotherapy :PatientSupportif psycotherapy Psychoeducation Family : Psychoeducation aboutPatient disorderTeraphy

PROGNOSIS Quo ad vitam : dubia ad bonamQuo ad fungsionam : dubia ad bonamQuo ad sanactionam : dubia ad malam

CASE ANALYSESThe diagnosis of the patient got from history and physical

examination. Patient’s chief complains are raging violently, taking the fire, holding the knife, talking alone, laughing alone, dancing alone, walking alone without direction since one day before admission. Physical examination shows normal blood pressure of 130/90 mmHg. Cardiovascular, respiratory, gastrointestinal, and neurologic examination shows no abnormalities.

One month before admission, patient came to Medan to visit her youngest brother. There, the patient got hard pressure from her brother. When the patient wish to came back to Batusangkar, the brother refused her wish. Her brother have rough personality. So, the patient had pressure. She sat alone in the traffic light in Medan. She had pee in the people’s home. Then, her brother took the patient to Batusangkar. Arrived at home in Batusangkar, the patient raged violently, took the fire, held the knife, talked alone, laughed alone, danced alone, walked alone without direction. Then, the son in law took the patient to the general hospital M. Djamil, Padang.

CASE ANALYSESPatient lives alone since 2 years ago. Previously, she lived

with her daughter and son in law and 3 grandsons. The patient decided to live alone because she felt like to be alone and didn’t like to be bridled. The daughter and family visited the patient once a week; the distance is about one km. Their communication is good. Patient lives in an old house, like a cottage. There is no vehicle, there is electricity, and the water is from PDAM. The salary got from herself as vegetable seller and youngest brother from Medan as rice seller. Family didn’t know the number she got every month. The salary is enough for her daily needs.

On 2010, the patient had suspicious to her neighbors. She felt that the neighbors liked to talk about her, competed her and others, ordered her anything. On 2013, the patient had psychiatry disorder like talked alone, walked alone without direction, and danced alone. Then, her daughter and son in law took the patient to indigenous medical practitioner. The practitioner didn’t give some traditional medicine, but only gave some magic formula to patient. The patient got better.

CASE ANALYSESThe patient had two times of marriage. First marriage with first husband was divorced because of dishonesty. The husband was back to his first wife. Then, the patient married for the second time, got one daughter. They divorced on 1978 because patient felt that the second husband was lazy, less in attention and didn’t have hard work. 2 years ago, her ex-second husband died, she didn’t depress.

Patient’s eldest sister had psychiatric disorder. Her sister liked to be alone, keep silent, and not interested in talking each other. According to the family, it happened because she got the magic formula after eating food in a meeting. There is no medical record history including admission and control to doctor.

Psychic contact can be done, proper, persist for long duration, euthym, stabile, good controlling, echt, shallow, narrow differentiation scale, slow emotion flow Intellectual function unimpaired. There are disturbed discriminative insight and judgment also present of Sperrung and Hemmung in thinking process.

Patient is diagnosed scyzoafective disorder with manic type as stated in the PPDGJ-III. The symptoms consist of disturbed time orientation, present of animosity and revenge, suspicious to her son in-law and neighbourhood also unimpaired sensation and perception. These symptoms are not obvious nor diagnostic. Might be the examination was not perform in early time and patient have gotten some drug prescribed. So these minimalize or loss diagnostic symptomps. Triggering event is not clear. Her divorce with her husband is believed to play a role in present symptom also less attention from her only child make the condition worse.

Given Prognosis to this patient is bad, because the disease has repeated and there is no adequate family support. Patient is given haloperidol 5mg 3x1 tablet, B vitamine 50mg 3x1 tablet, and C vitamine 20 3x1 tablet.

SCHEME OF DISEASE HISTORY