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

Dafit Fernandes / 33 years old

MR

79902

Gender

Male.

Place and date of birth

Pariaman, September 23th 1978

Marital status

Single

Address

Pancasila Street No. 30 RT 03 RW 01 Sungai Penuh, Kerinci

Occupation/School

No Occupation/Senior High School

Religion

Islam

Citizen

Indonesian

Tribe

Minangnese

Allo-anamnesis was given by:

Name/Age

: Armen Filma/40 years old

Address

: Sungai Penuh, Kerinci (0811742897)

Occupation

: Trader

Relationship with patient

: Older Brother

A. Internal Status
General appearance
Blood pressure
Pulse
Respiration
Temperature
Body Shape
Height
Weight
Cardiovascular system
Digestive system
Specific disorder

: Compos Mentis
: 120/70 mmHg
: easily palpable, regular, 81x per minute,
: abdominotorakal pattern, regular, 21x per minute
: 36,90C
: astenikus
: 180 cm
: 78 kg
: No abnormality detected
: No abnormality detected
: No abnormality detected
1

B. Neurological Status
Cranial Nervous (five senses)
: Vision, smelling, hearing, tasting, and tactil are well
Meningeal Signs
: None
High Intracranial Pressure Signs : None
Eyes
- Movement
: Free to all direction
- Perception
: No nystagmus, no diplopia
- Pupil
: Round and isokor
- Light Reflex
: +/+
- Convergence Reaction
: Not examined
- Ophtalmoscopic examination : Not examined
Motoric
- Tonus
: Eutonus, tremor (+/+)
- Turgor
: Good
- Strength
: Good
- Coordination
: Good
- Reflex
: Physiologic (+/+), pathologic (-/-)
Sensibility
: No abnormality detected
Vegetative Function
: Good appetite, sleep well
Basic Function
: No abnormality detected
Specific disorder
- Rigid
: None
- Tremor
: +/+
- Nasal Stiffness : None
- Oculogyric Crisis : None
- Torticolis
: None
- Others
: None
Laboratorium (August, 9th 2011)
Hemoglobin
: 11 g/dl
Leukocyte
: 8300/mm3
Thrombocyte
: 210.000/mm3
Diff Count
: 0/0/1/83/12/4
Blood Type
:A
Autoanamnesis, November 7th 2011 :
Questions
Assalamualaikum

Answers

Interpretation

Waalaikumsalam

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

cooperative

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

bang?

mangecekan

Sia
abang

nan Perawatnyo

mah.

Tapi

buliah keluarga bang dafit alun juo

pulang?

Personal orientation is good

manjapuik lai. Tingga masalah

administrasinyo se lai mah. Tu
lah. Kawan-kawan ko acok
dicaliak

dek

keluarganyo.

Bang Dafit indak do. (hening

sejenak)
Bilo terakhir keluarga Bang Saminggu nan lewat.

Time orientation is good

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

Dek a Bang Dafit dibawo Antahlah. Padahal Bang Dafit

kamari?

Time orientation is good

ndak sakik jiwa dibawo dek

Uda

Bang

Dafit

kamari.

nio

pulang.

Discriminative insight is
disorder

Dikabek lho tu
Baa kok dikabek bang?

Yo.

Marabo

Manga abang dibawo kasiko.

Abang

ndak

sakik

Much, Fast

do.

Keluarga Abang tu nan sakik

mah.

Gilo.

Bang

Davit
3

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

Iyo

mah

diak.

mah. Maa pulo keluarga Bang Dituduahnyo ge awak main

Dafit

punyo

ilmu.

Dellucion is present

Maa poyok, onani. Tu makonyo

amuahnyo

mampamainan kurang lalok Bang Dafit ko

Bang Dafit

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

Akustik and olfactoric

hallucination are present

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

Ado pernah nampak bayang- Ha ndak ado do

Visual hallucination is absent

bayang Bang Dafit ndak?

Bang Dafit, wak barituang 93
stek yo. 100 7 bara?
Kurang 7 liak

Concentration is not good

Hmm86
4

enough
Kurangi 7

Hmm.74..eh ndak nak.. bara

tadi?

86 - 7

Oo iyo.. hmmm.. 79 nak

Bang Dafit suko pai jalan- Ndak do do

Vagabondage is absent

jalan surang? Ndak tantu arah.

Ndak sadar se dima
Bang Dafit suko mambaka- Mambaka
baka ndak?

saroknyo

diak

Pyromani is absent

(tertawa).

Bang Dafit ado maraso takuik- Ndak do Bang takuik do. Bang
takuik ndak?

Dafit urang bagak mah

Raso badoso lai?

Ka sia Bang Dafit badoso.

Keluarga tu nyo yang jaek ka

Phobia is absent

Feeling guilty is absent

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

Central pattern is present

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

pitih di jalan, apo nan ka Bang

tambahan pitih lanjo

Discriminative judgement is

karajoan?

disorder

Kan ndak pitih abang tu do

Kan

lah

tacampak

mah.

mah. Baa kok baambiak?

Berarti ndak paralu lai dek

5

urangnyo
O iyo Bang Dafit. Buek lah
gambar agak ciek. Trus
manulis disiko

Oh jadih
Ha ko lah salasai.

Bang Dafit lai ingek namo

Lai. Namo adiak Meta, nan

Kami?

iko Jonni. Eh Lah jam 4 ha.

Memory is good

Bang Dafit ambiak rokok dulu

yo diak.. Lai buliah kan. Beko
Bang Dafit carito liak.
Yo Bang. Kami ka pulang pulo Pulang lai? Lai di Padang ko
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.
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
6

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.
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.
7

Premorbid history
Infant
:
born spontaneously, birth was assisted by midwife, no history of
Childhood
Adolescence

jaundice, cyanosis, and seizure.

growth and development according to his age.
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

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
:
compos mentis/good
Attitude
:
cooperative
Motoric
:
active
Facial expression
:
rich
Verbalization
:
speak clearly
Physic contact
:
could be done / inappropriate / long enough
Attention
:
good
Initiative
:
good
2. Specific condition
A. Affective
1. Affective condition
:
hypertim
2. Emotional :
a. Stability
:
stable
b. Control
:
good enough
c. Echt/unecht
:
echt
d. Einfuhlung
:
inadequat
e. Deep/shallow
:
shallow
f. Differentiation scale
:
narrow
g. Emotional flow
:
fast
B. Intellectual condition of function
a. Memory
:
good
b. Concentration
:
not good enough
c. Orientation
:
good
d. General and schooling knowledge : can not predicted
e. Discriminative insight
:
disturbed
f. Intelligence prediction
:
average
g. Discriminative judgment
:
disturbed
h. Intelectual deterioration
:
none
9

C. Sensation and perception abnormalities

1. Illusion
: none
2. Hallucination
:
Acoustic
: present, since 3 month ago decrease in last 7
Visual
Olfactory

days ( hearing short sircuit sound)

: none
: present, since 3 month ago decrease in last 7

Tactile
Gustatory

days (scorch odor)

: none
: none

D. Thought process condition

1. Speed of thought processs
2. Quality of thought process:
a. Clear and sharp
b. Circumstantial
c. Incoherent
d. Sperrung
e. Hemmung
f. Flight of ideas
g. Verbigeration
h. Preservation
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

fast

:
:
:
:
:
:
:
:

clear and sharp enough

none
none
none
none
none
none
none

:
:
:
:
:
:
:
:
:
:
:
:

present
none
none
present
none
none
none
none
much
none
none
none

E. Instinctual drive and behavior abnormalities

a. Abulia
:
none
b. Stupor
:
none
c. Raptus/impulsivity
:
none
d. Excitement state
:
present, since 3 month ago, decrease in
the last 1 and half months
e. Sexual deviation
:
none
f. Echopraxia
:
none
10

g. Vagabondage
h. Pyromania
i. Mannerism
j. Others
F. Over anxiety
G. Reality testing ability

:
:
:
:
:
:

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.
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.
11

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
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.

F.31.2 Bipolar Affective Disorder Manic Episode with Psychotic Symptoms

No Diagnosis.

III.

Marijuana abuse and alcoholic history

IV.

Drug Withdrawal

V.

GAF 41-50.
12

DIFFERENTIAL DIAGNOSIS
I.

F 31.6 Bipolar Affective Disorder Mixed Episode

II.

F 25.0 Manic type schizoaffective

THERAPY

Risperidon 2 x 1 mg

Haloperidol 2 x 5 mg

THP 2 x 2 mg

PROGNOSIS
Clinical

dubia at malam

Functional

dubia at malam

Social

dubia at malam

SUGGESTION FOR THERAPY

Education to the family

13