Case Presentation A 33 years old man was admitted to HB Saanin asylums emergency unit on September 11th, 2011 at 11 a.

m and escorted by his family. This patient was permitted to hospitalize by dr. Fadil. Sick for the fifth time and hospitalized for the fourth time. The sickness is worse than before. Patient identity: Name and Age MR Gender Place and date of birth Marital status Address Occupation/School Religion Citizen Tribe Name/Age Address Occupation Relationship with patient A. Internal Status General appearance Blood pressure Pulse Respiration Temperature Body Shape : Compos Mentis : 120/70 mmHg : easily palpable, regular, 81x per minute, : abdominotorakal pattern, regular, 21x per minute : 36,90C : astenikus
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: : : : : : : : : :

Dafit Fernandes / 33 years old 79902 Male. Pariaman, September 23th 1978 Single Pancasila Street No. 30 RT 03 RW 01 Sungai Penuh, Kerinci No Occupation/Senior High School Islam Indonesian Minangnese

Allo-anamnesis was given by: : Armen Filma/40 years old : Sungai Penuh, Kerinci (0811742897) : Trader : Older Brother

Height Weight

: 180 cm : 78 kg

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

B. Neurological Status Cranial Nervous (five senses) Meningeal Signs : Vision, smelling, hearing, tasting, and tactil are well : None

High Intracranial Pressure Signs : None Eyes Movement Perception Pupil Light Reflex : Free to all direction : No nystagmus, no diplopia : Round and isokor : +/+ : Not examined

Convergence Reaction

Ophtalmoscopic examination : Not examined

Motoric Tonus Turgor Strength : Eutonus, tremor (+/+) : Good : Good

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Coordination Reflex

: Good : Physiologic (+/+), pathologic (-/-) : No abnormality detected : Good appetite, sleep well : No abnormality detected

Sensibility Vegetative Function Basic Function Specific disorder Rigid Tremor Nasal Stiffness

: None : +/+ : None

Oculogyric Crisis : None Torticolis Others : None : None

Laboratorium (August, 9th 2011) Hemoglobin Leukocyte Thrombocyte Diff Count Blood Type : 11 g/dl : 8300/mm3 : 210.000/mm3 : 0/0/1/83/12/4 :A

Autoanamnesis, November 7th 2011 :

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Questions Assalamualaikum

Answers Waalaikumsalam

Interpretation

Da Dafit wak Meta, ko Jonni. Jadih. Disikolah wak duduak Kami nio mamariso Da Dafit. diak. Bang Dafit santa lai Nanyo-nanyo sabanta pulang mah. O iyo. Salamaik hari rayo diak. Patang Idul Adha maa. O yo. Samo-samo yo bang. Lai. Disiko se sumbayangnyo. Lai sumbayang bang patang? Bia lah. Santa lai bang Dafit pulangnyo mah. (tersenyum lebar) Iyo pulang? bang? Sia abang nan Perawatnyo mah. Tapi Personal orientation is good cooperative

mangecekan

buliah keluarga bang dafit alun juo manjapuik lai. Tingga masalah administrasinyo se lai mah. Tu lah. Kawan-kawan ko acok dicaliak sejenak) dek keluarganyo. Bang Dafit indak do. (hening

Bilo terakhir keluarga Bang Saminggu nan lewat. Dafit kamari? Ha kan baru-baru ko tu mah Eh iyo nak diak (tersenyum lebar) Lah bara lamo bang Dafit Mungkin kiro-kiro alah 1,5 disiko? bulan mah

Time orientation is good

Time orientation is good

Dek a Bang Dafit dibawo Antahlah. Padahal Bang Dafit kamari? ndak sakik jiwa dibawo dek Uda Bang Dafit kamari. Dikabek lho tu

Discriminative insight is disorder

Baa kok dikabek bang?

Yo.

Marabo ndak Gilo.

nio

pulang. do. Much, Fast Davit

Manga abang dibawo kasiko. Abang mah. sakik Bang Keluarga Abang tu nan sakik dikarajoan dek urang mah. Keluarga Bang Davit punyo karajo. Nyo bailmu mah. Dipamainannyo Bang Dafit. Bang Dafit dituduah suko onani bagai. Pamainan poyok. Ntah apo tu. Ko ndak juo diurusnyo administrasi pulang Bang Dafit. Bang Dafit ko ado-ado se Ndee Dafit punyo ilmu. Iyo mah diak. Dellucion is present

mah. Maa pulo keluarga Bang Dituduahnyo ge awak main Maa poyok, onani. Tu makonyo mah. Apolai lampu kamar koslet. Suaronyo manggaduah. Baun anguih mah. Lai tadanga dek adiak. Ndak lamak lalok Bang Dafit do. Ndak ado tadanga dek kami Sakareh tu ha do bang Lah bara lamo tadanga koslet Sajak disiko. Tapi saminggu tu Bang Dafit? ko lah ndak sakareh biasonyo tadanga do. Waktu dirumah listrik koslet pulo mah. Indak juo dipelokkan uda do amuahnyo Bang Dafit mampamainan kurang lalok Bang Dafit ko

Akustik and olfactoric hallucination are present

Ado pernah nampak bayang- Ha ndak ado do bayang Bang Dafit ndak? Bang Dafit, wak barituang 93 stek yo. 100 7 bara? Kurang 7 liak Kurangi 7 Hmm86 Hmm.74..eh ndak nak.. bara tadi? 86 - 7 Oo iyo.. hmmm.. 79 nak

Visual hallucination is absent

Concentration is not good enough

Bang Dafit suko pai jalan- Ndak do do jalan surang? Ndak tantu arah. Ndak sadar se dima Bang Dafit suko mambaka- Mambaka baka ndak? (tertawa). saroknyo diak

Vagabondage is absent

Pyromani is absent

Bang Dafit ado maraso takuik- Ndak do Bang takuik do. Bang takuik ndak? Raso badoso lai? Dafit urang bagak mah Ka sia Bang Dafit badoso. Keluarga tu nyo yang jaek ka Bang Davit. Dikarajoannyo jo ilmu. Dituduahnyo gai Bang Dafit onani, main poyok. Ko alun juo diurus administrasi pulang ha Hmm.. Tolong Bang Dafit telponan Da Men tu ciek. Suruahnyo maurus administrasi. Japuik Bang Dafit lai. Bang Dafit ka pulang lai. Nio basobok jo kawan-kawan bagai. Kalo Bang Dafit Basobok Bang Dafit ambiak untuak

Phobia is absent

Feeling guilty is absent

Central pattern is present

pitih di jalan, apo nan ka Bang karajoan? Kan ndak pitih abang tu do mah. Baa kok baambiak?

tambahan pitih lanjo Discriminative judgement is Kan lah tacampak mah. disorder Berarti ndak paralu lai dek urangnyo

O iyo Bang Dafit. Buek lah gambar agak ciek. Trus manulis disiko Bang Dafit lai ingek namo Kami?

Oh jadih Ha ko lah salasai. Lai. Namo adiak Meta, nan iko Jonni. Eh Lah jam 4 ha. Bang Dafit ambiak rokok dulu yo diak.. Lai buliah kan. Beko Bang Dafit carito liak. Memory is good

Yo Bang. Kami ka pulang Pulang lai? Lai di Padang ko pulo lai mah juo tingga?

Lai Bang.. Yo lah.. makasi yo Yo samo-samo.. (tertawa) Bang..

Alloanamnesis: Primary couse of hospitalization Patient was restless, almost never slept at night, talked a lot, inconsequential, irritable, suspicious of others, often threatening, like chasing other people, hitting a parked vehicle with wooden beams, destroying household appliances, since 3 months before hospitalized.

Present complain of patient There is no complaint at this time.

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History of illness: 1999 (around October) Patient were studied at the University of Eka Sakti. GPA of patient is always low and tends to decrease. 1st semester , GPA was 2.2, 2nd semester , GPA was 1.5, 3 rd semester, GPA was 1.5, and 4th semester, GPA was 1. Patient began to blame the lecturer for the value obtained. Patient felt that he is always correct in answering the exam questions and tasks. After that the patient began to forget things. Forgot to create a task, forgot to close the rice and side dishes, forgot to turn off the lights, stoves, and others. Patient using marijuana in the year, also ever use a syringe, so patient drop out. Patient become lazy, likes silence, muse, and often looked sad. Until one day, the patient ran home leaving his nephew for a walk on the grounds chasing bad guys. When in fact there is no person who intends evil to him. Then the patient was taken to Puti Bungsu asylum for treatment, and was given outpatient treatment.

2000 (beginning of the year) After several months of treatment, no installment, the patient was brought back to the Puti Bungsu Hospital. Patient treated at Puti Bungsu asylum for about 23 days. Patient went home in a state of calm and on a regular basis. The patient always controlled his present condition after discharge.

2007 (forgot month) Patient was restless, angry, always suspicious of other people, hitting a parked vehicle with wood beams, and lots of talking. Previously, patient was not taking medication regularly since last year. The patient was taken to Puti Bungsu and treated for about 25 days. Patient went home in a state of calm and on a regular basis. The patient always controlled his present condition after discharge.
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2010 (October) Patient often visited the house of relatives, neighbours and friends, because that is still in an atmosphere of Eid. Each visit, patient always asked for were treated with coffee. Until that day, he drank up to 8 cups of coffee at the shop. Suddenly, throwing his coffee cup on the floor. From then on, he complained that he could not sleep. Patient was restless, loquacious, inconsequential, alternation, always felt everything the world mean for him, felt as if by magic, and complained about short sircuit sound. The patient was taken to the HB Saanin asylum and hospitalized there about 1.5 months. Patient went home in a state of calm and on a regular basis. The patient always controlled his present condition after discharge.

2011 (September) Since early 2011, the patient did not want to take medication because they feel healthy. The patient began to show abnormalities in June. The patient was restless, almost never slept at night, talked a lot, inconsequential, irritable, suspicious of others, often threatening, like chasing other people, hitting a parked vehicle with wooden beams, destroying household appliances, felt as if by magic, and complained about short sircuit sound. The patient refused to hospital. Finally Patients family deceived him and took the patient to a HB Saanin asylum for treatment.

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.
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Adolescence

had a lot of friends, easy making new friends and outgoing person

Educational background Elementary School at SD N 27 Sungai Penuh, graduated in 6 years, top ten Junior High School at SMP N 8 Sungai Penuh, graduated in 3 years, top ten Senior High School at SMA N 1 Sungai Penuh, graduated in 3 years, achievement decreased

Social economy history Living with his parents, had a permanent house, had a TV and electricity on it, water supply from Municipal Water Corporation, had no home-phone, had a motorcycle. His parents and him have no occupation. He got money from his older brother. Usually, Rp. 20.000/day, and he feels enough.

Biological development background Head traumas history was present, but not vomiting and was never hospitalized after trauma No history of malaria, typhoid, or brain and neurological disease Marijuana abuse and alcoholic history

Family history of illness

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There were no family members that has same symptoms like this.

Graphic of illness

EXPLANATION AND CONCLUSION OF PSYCHIATRIC EXAMINATION Examination is on November 7th 2011, 3 p.m WIB 1. General appearance Consciousness/sensorial Attitude Motoric : : : compos mentis/good cooperative active
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Facial expression Verbalization Physic contact Attention Initiative 2. Specific condition A. Affective

: : : : :

rich speak clearly could be done / inappropriate / long enough good good

1. Affective condition 2. Emotional : a. Stability b. Control c. Echt/unecht d. Einfuhlung e. Deep/shallow f. Differentiation scale g. Emotional flow

hypertim

: : : : : : :

stable good enough echt inadequat shallow narrow fast

B. Intellectual condition of function a. Memory b. Concentration c. Orientation : : : good not good enough good
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d. General and schooling knowledge : e. Discriminative insight f. Intelligence prediction g. Discriminative judgment h. Intelectual deterioration : : : :

can not predicted

disturbed average disturbed none

C. Sensation and perception abnormalities 1. Illusion 2. Hallucination Acoustic : none : : present, since 3 month ago decrease in last 7 days ( hearing short sircuit sound) Visual Olfactory : none : present, since 3 month ago decrease in last 7 days (scorch odor) Tactile Gustatory : none : none

D. Thought process condition 1. Speed of thought processs 2. Quality of thought process: a. Clear and sharp b. Circumstantial : : clear and sharp enough none
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fast

c. Incoherent d. Sperrung e. Hemmung f. Flight of ideas g. Verbigeration h. Preservation

: : : : : :

none none none none none none

3. Thought condition a. Central pattern b. Phobia c. Obsession d. Delusion e. Suspicion f. Confabulation g. Repulsion h. Inferior feeling i. Much/little j. Feeling guilty k. Hypochondria l. Others : : : : : : : : : : : : present none none present none none none none much none none none

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E. Instinctual drive and behavior abnormalities a. Abulia b. Stupor c. Raptus/impulsivity d. Excitement state : : : : none none none present, since 3 month ago, decrease in the last 1 and half months e. Sexual deviation f. Echopraxia g. Vagabondage h. Pyromania i. Mannerism j. Others F. Over anxiety G. Reality testing ability : : : : : : : : none none none none none none none disturb in behavior, feeling and thinking

MULTIPLE AXIS RESUME Axis I. Clinical Syndrome Patient was restless, almost never slept at night, talked a lot, inconsequential, irritable, suspicious of others, often threatening, like chasing other people, hitting a parked vehicle with wooden beams, destroying household appliances, lack of sleep and adequate diet since 3 months before hospitalized. Sick for the fifth time and hospitalized for the fourth time. The sickness is worse than before.
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Phsyciatric examination: General Appeareance: compos mentis, cooperative, active, rich, can speak clearly, psychic contact could be done, inappropriate and long enough. Specific condition: a. Affective condition: hypertim, stable, good enough, echt, inadequate, shallow, narrow, fast. b. Intellectual condition and function: good memory, concentration is not good enough, good orientation, absent intelectual deterioration, discriminative insight and judgment are disturbed. c. Sensation and perception abnormalities: no illusion, acoustic and olfactoric hallucination present since 3 month ago, decrease in last 7 days. d. Thought process condition: fast, clear and sharp enough, central pattern present, delusion present, much. e. Instinctual drive and behavior abnormalities: excitement state is present, since 3 months ago, decrease in the last one and half months f. Overt anxiety: none g. Reality testing ability, disturbed: behavior, feeling and thinking Axis II : Personality Disorder and Mental Retardation Disorders Personality: outgoing, has a lot of friend Mental retardation: none Axis III : General Medical Condition Head traumas history was present No history of malaria, typhoid, or brain and neurological disease
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Marijuana abuse and alcoholic history

Axis IV : Phsychosocial Stressor and Environment Drug withdrawal Axis V: Global Assessment of Function Social relationship couldnt be done since sick Spending time with watching TV, travelling, couldnt be done since sick

MULTIPLE AXIS DIAGNOSIS I. II. III. IV. V. F.31.2 Bipolar Affective Disorder Manic Episode with Psychotic Symptoms No Diagnosis. Marijuana abuse and alcoholic history Drug Withdrawal GAF 41-50.

DIFFERENTIAL DIAGNOSIS I. II. F 31.6 Bipolar Affective Disorder Mixed Episode F 25.0 Manic type schizoaffective

THERAPY Risperidon 2 x 1 mg Haloperidol 2 x 5 mg

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THP 2 x 2 mg

PROGNOSIS Clinical Functional Social : : : dubia at malam dubia at malam dubia at malam

SUGGESTION FOR THERAPY Education to the family

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