Case Presentation

A 41 years old man was admitted to policlinic DR M Djamil hospital on

May 27th 2015, and escorted by his family. This patient didnt want to eat anything
and always cage himself at home since 1 week before came to hospital. Sick for
the fourth time and hospitalized for the first time. The sickness is worse than
before.
Patient identity:
Name and Age

Sumardi/ 41 years old

MR

60. 74. 54

Gender

Male

Place and date of birth

Padang, March 15th 1974

Marital status

Separate

Address

Simpang Maut Dalam road RT 1 RW 3 No. I

Kelurahan Bungo Pasang Koto Tangah

Occupation/School

Driver/ Senior High School

Religion

Islam

Citizen

Indonesian

Tribe

Melayu

A. Internal Status
General Condition
Awareness
Blood pressure
Pulse

: Moderate ill
: Composmentis
: 120/80 mmHg
: regular, strong

Respiration

times/minute
:moderate, torachoabdominal, frequency 20

Temperature
Height
Weight
Nutritional status
Cardiovascular system
Inspection

times/minute
: 36,80C
: 165 cm
: 55 kg
: well
:
:Ictus cordis not visible

lift,

frequency

88

Palpation

: Ictus palpable around one finger medial to

left midclavicular line, 5th intercostal
space

Percussion : Up: 2nd intercostal space, left: one finger

medial to left midclavicular line, right:
dextra sternalis line
Auscultation: Normal and regular heart sound, murmurs
absent
Respiratoric System

Inspection : Simetric statically and dinamically

Palpation

: Fremitus similar between left and right

chest

Percusion : Sonor all over the thorax

Auscultation: Vesicular breath sound present, ronchi
absent, wheezing absent
Specific abnormalities

B. Neurologic Status
GCS

: E4M6V5

Meningeal Sign

: absent

Extrapiramidal sign
-

Hand tremor

: absent

Akatisia

: absent

Bradikinesia

: absent

Way of stepping: normal

Balance

: non disturbed

Rigiditas

: absent

Motoric

Sensorik

: 555 555
freely in any direction
555 555
: well propioseptif and exteroseptif

Refleks

: Phisiologic reflex (+), phatologic reflex (-)

Laboratorium result:

Hb
: 14,1 mg/dl
Trombosit : 243.000/mm3
Leukosit : 9700/mm3
Eritrosit
: 5,2 juta/mm3
LED
: 1 mm/ jam
SGOT/ SGPT : 22 u/l / 12 u/l
Autoanamnesis, May 6th 2015 :
Questions
Answers
Assalammualaikum Pak , Waalaikumsalam,

Iya

Interpretation
Composmentis

saya dokter muda dewi boleh

dan dita, boleh ngobrolngobrol sebentar pak?
Siapa nama pak?
Berapa umur bapak?
Sajak bilo apak disiko?
Baa

kok

yang lalu
apak Waktu tu

dibaok

kasiko?
Sia

yang

Sumardi
41
Alah sekitar seminggu
dek

awak

marusuah di rumah
baok

Cooperative

Diskriminatif insight is
good

apak Adiak yang cewek samo

kamari?

yang cowok

Person orientation is
good

Baa apak waktu dibaok Ambo barubek ka poli jo

kasiko pak?

adiak awak tu dibaok

Marusuah baa apak?

awak ka bagian jiwa ko

Ndak ado do, awak
maraso kecewa samo diri

Situation orientation is
good

Inferior feeling

surang bu, dek itu awak

marusuah tu
Baa tu kok dek maraso Awak patang ko diajak
kecewa jo diri
apak?

surang dek kakak ka jakarta,

tapi awak ndak nio, ndak

jadi awak ka jakarta

Menurut apak, apak yang Indak buk, awak waktu
marusuah-rusuah tu wajar tu dek emosi ka diri
ndak pak?

awak

Discriminative judgment

Ado

apak

pernah

mancaliak

bayangan- diam

bayangan pak?
Halutination acustic (+)
Baa pak? Ado apak pernah mancaliak-caliak
mancaliak-caliak
atau

kini

urang indak lai buk, tapi kini

bayangan-bayangan ado

pak?

wak

mandanga-

danga urang manggia-

Halutination visual (+)

manggia awak
halutination accustic (+)
Dulu bana berarti pernah Iyo pernah buk, lah lamo
apak maliek-liek bayangan ado bayangan gitu se
pak?

lewat nampak dek awak

halutination olfactoric

Kalau

yang

manggia

manggia- Manggia-manggia

apak

katonyo?

tu

Ado

buk,

(+)

apo lai pernah disuruahnyo

nyo wak pai kalua dek nyo

marintahan apak untuak buk

babuek sesuatu pak?
Waktu

itu,

ado

apak Ado buk, bau got kok

manciuman bau-bau gitu?

ndak wc buk, kadangkadang yg harum ado lo

Sajak bilo se apak maraso Patang-patang tu alah

ado

mandanga-danga, ado lo buk, sajak di rs ko

samo mambaun baun tu makin batambah rasonyo

pak?

Kalau

maraso

dipacik2 Lai

lo

buk,

rasonyo

halutination tactil (+)

ado apak?

patang ntah patang ciek

lai ado yang macik an
dari belakang

Kini apo nan taraso lai pak Kini lah agak biaso buk,
sum? Ado apak maraso lai ndak sadiah-sadiah
sadiah-sadiah?

bana lai
Inferior feeling positive

Sabalum

ko

baa Iyo awak dek kecewa tu,

memangnyo pak?
Pernah

apak

tu ibo se ati wak

tapikia Lai buk pernah

sampai nio akhiri hidup?

Oiyo pak, apak sum tahu Tau, di rumah sakit m Place orientation is good
kini dima pak?
djamil , di bagian jiwa
Tahun bara kini ko lai tau 2015
time orientation is

apak?
Bulan apo pak?

Mei

Tanggal?

disturbed

Hari apo kini ko pak?

Kamis
Ado apak maraso takuik- Indak

Fobia (-)

takuik jo sesuatu pak?

Oh gitu, Iyo lah, makasih Iyo (menggangguk)
yo pak, ala nio kami
tanyo-tanyo. Istirahat lah
lai pak.

Alloanamnesis:
Allo-anamnesis was given by:
Name/Age

: Devi Sumarni/ 32 years old

Address

: Bungo Kasang, Koto tangah

Occupation

: Nurse

Relationship with patient

: youngest Sister
5

I. Chief complain:
Patient didnt want to eat anything and cage himself at home since 1 week
before came to hospital.
II. Recent History:
-

Patient often silent, cage himself at home and didnt want to eat since 1
week before came to hospital

Patient noisy and worried since 1 week before came to hospital

Family said that patient wasnt enough sleep and didnt want to eat
medicine since 1 week before came to hospital, family known that because
total of medicine didnt decrease, and when family ask the patient, the
patient denial and said that he has eat his medicine.

Patient often bring sharp weapon to every place.

Family said that patient act like this because economicals patient is lower
that his brothers and sisters.

Patient is the second child of six children and felt responsible for his
younger brothers and sisters but cant afford economically, especially after
his parents died.

Patient felt chased and hear some whisper since 1 week before came to
hospital, this feeling is increase when patient stay in hospital

III.Previous History:
1. Psychiatry disorder history
Year 1996
At the first, patience saw black shadow at night. Since that,
patience was be reserved. His family brought the patience to
shaman for 2 months. After that, patience saw black shadow again
6

and hear the voice that told him not to take medication. Then,
patience increases to cage himself at home.
Year 2000-2003
Patience try to take alternative medication but there is no
improvement. Then, his sister take him to psychiatrist for 2
months. Because lack of cost, patience was referenced to HB
Saanin hospital and get two drugs that is haloperidol and
diazepam. After that patience always control himself to HB Saanin
hospital and then he can do activity normally as priest in a
mosque.
Year 2003-2008
Patience was controlled, still consume drugs and always consult to
policlinic by himself.
Year 2008-2014
Patience went to Kalimantan and worked there for 1 year with his
brother. Patience still get medication, was controlled and can do
activity normally.
Year 2014
Patience was divorced and patience cage himself

2. Medical disorder history

The patient didnt have some medical history disease,
surgery history, accident history, neurologic disorder, tumor,
consciousness disorder, HIV.

IV.

Private History
1. Prenatal/ Perinatal period
Patient was born as the 2th child of 6 siblings. Patient was born on
time and norm weight. The pregnancy was helped by midwife and
cried.

2. Early pediatric period (0-3 years)

Patient grew and developed healthy like others.
3. Middle pediatric period (3-11 years)
Patient grew and developed healthy like others, had friends.
4. Late pediatric period and adolescence period
Patient grew and developed healthy like others, had friends.
5. Adult period
a. Education history
The patient got education until senior high school.
b. Job history
At 2002, patience was a teacher in a mosque
At 2009, patience went to Kalimantan and work in a hotel as
chef. Patience come back to Padang at 2010, and work as
driver.
c. Marriage history
He married in 2004 and have a girl 10 years old. Patience
divorce because his wife cant manage him.
d. Religion history
The patient is Moeslim. He believes to god and prays 5 times
a day. He often reads religion books.
e. Psychosexual history
There is no history of psychosexual history.
f. Social activity
The patient and neighbor had no conflict.
g. Violation of law history
There is no history of violation of law

Family history of illness

There were no family members that has same symptoms like this.
Graphic of illness
1994

1996

2003

2008

2014

2015

Recent life situation

The patient lives with his sister in the house. Their communication is good.
Familys perception and hope
Family wanted the patient get well soon and continue his live.

I. General Condition
Awareness

: Composmentis

Attention

: less

Attitude

: apatis

Inisiative

: less

Motoric behaviour

: hypoactive
9

Facial expression

: poor

Speech and verbal

: can speak, not enough fluently and clearly

Physical contact

: can be done, less, and short-time

II. Spesific condition

A. Natural State of Feeling
1. Afective condition : hipothym
2. Emotion Living

: a. Stability

: labil

b. Control

: less

c. ech unecht

: echt

d. einfuhlung ( invoelaarhaid )

: inadequate

e. deep-shallow

: shallow

f. differentiation scale

: narrow

g. emotion flow

: slow

B. Intelectual Function
a. Memory (amnesia)

: less

b. Concentration

: inadequat

c. Orientation
( time, spatial, personal, situation)

: disturbed in time

d. general knowledge

: cannot evaluated

e. discriminative insight

: good

f. alleged level of intelegency

: good

g. discriminative judgment

: good

h. intelectual deterioration

: absent

C.Perseption and sensation anomaly

a. illution
b.halutination

: absent
- acustic

: positive

- visual

: positive

- olfatorik

: positive

- tactil

: positive

10

D. Way of Thingking
1. Psikomobilitas

: slow

2. Thingking process
a. clear and sharp

: not clear and not sharp

b. Sirkumstansial

: absent

a. Inkoherrent

: absent

b. Sperrung

: absent

c. Hemmung

: absent

d. Flight of ideas

: absent

e. Verbigerasi Persevarative ( Persevaratich )

: absent

3. Contents
a. Central pattern

: absent

b. Phobia

: absent

c. Obsess

: absent

d. Dellusion

: absent

e. Suspicion

: absent

f. Confabulation

: absent

g. Animosity/revenge

: absent

h. Inferior feeling

: positive

i. Much/less

: less

j. Guilty feeling

: positive

k. Hippochondria
l. Others

: absent
:-

E. Instinctual impulse disorders

a. Abulia

: absent

b. Stupor

: absent

c. Raptus / impulsivitas

: absent

d. excitement state

: positive

e. sexual deviation

: absent

f. Echophraxia

: absent

11

g. Vagabondage

: absent

h. Piromani

: absent

i. Mannerisme

: absent

j. Others

:-

F. Overt anxiety

: positive, less

G. Relation to reality

: disturbed(mind,feel, behaviour)

VI. Multiaxial Evaluation

Axis I. Clinical Syndrome
Patience didnt want to eat anything and acge himself at home since one week
before come to hospital.
General condition : composmentis, apatis, less of inisiative , pasive
behaviour, poor facial expression, can speak, not enough fluently and clearly,
psychic contact can be done, less and short time.
Specific condition :
1. Natural State of Feeling : hypotim, labil, less, echt, inadequate, shallow,
narrow, and slow.
2. Intelectual function : memorizing abililty less, concentration ability
inadequate, orientation disturbed in time, general knowledge can not
evaluated, discriminative insight good, allegged level of intelegency good,
discriminative judgment good, intellectual deterioration absent.
3. Sensation and perception disorder: illusion absent, hallucination visual,
acustic, olfactoric, and tactil positive.
4. Process of Thinking: slow, not clear but not sharp, circumstancial absent,
incoherrent absent, Sperrung absent, Hemmung absent, flight of idea
absent, verbigeration absent, central pattern absent, phobia absent,
delusion absent, suspicion absent, confabulation absent, animosity and
revenge absent, inferior feeling positive, less, guilty feeling positive,
hypochondria absent.
5. Instinctual encouragement: abulia absent, stupor absent, raptus absent,
excitement state positive, sexual deviation absent, echophraxia absent,
vagabondage absent, pyromania absent, mannerisme absent.

12

6. Anxiety: positive, little

7. Relation to reality: disturbed(mind,feel, behaviour)
Axis II : Personality Disorder and Mental Retardation Disorders
Personality: obedient to his parent, diligent on prayer
Mental retardation: none
Axis III : General Medical Condition

Trauma capitiss history was not present

No history of malaria, typhoid, or brain and neurological disease
There is no consumption alcohol and drugs
Axis IV : Phsychosocial Stressor and Environment
Patient had no social problems with his friend and his family, patient is a
driver, live at permanent house with her sister and have a motorcycle
Axis V: Global Assessment of Function

Social relationship couldnt be done since sick

Spending time with cage himself at home and often reading some
religion book

MULTIPLE AXIS DIAGNOSIS

I.

F.25.1 Gangguan Schizoafektif Tipe Depresif

II.

No Diagnosis

III.

No Diagnosis

IV.

No Diagnosis

V.

GAF 60-51

DIFFERENTIAL DIAGNOSIS
I.

F 33.3 Gangguan depresi berulang, episode kini berat dengan gejala

psikotik

II.
III.

F 20.0 Skizofrenia Paranoid

F 20.4 Depresi pasca skozofrenia
13

THERAPY
-

Trifluoperazin 2x I tab @ 5 mg
Clorpromazine 1x I tab @ 100 mg
Vitamin C 3x I tab
Vitamin B 3x I tab
ECT

PROGNOSIS
Qua ad vitam

dubia at bonam

Qua ad sanam

dubia at malam

Qua ad fungsionam

dubia at malam

14