PRESENTASI KASUS

SKIZOAFEKTIF TIPE MANIK

Dokter Pembimbing:
Dr. Nur Dwi Esthi, Sp. KJ
Adil Hijri Muhammad
M. Gibran
Wandi
Adhitya Rachman

UNIVERSITAS MUHAMMADIYAH YOGYAKARTA

RSJP PROF. DR. SOEROJO MAGELANG

Patients Identity
Name
: Mrs. M
Age
: 50 years old
Sex
: female
Address : Lamongan
Job
:
Marital status : married
Ethnicity : Javanese
Educational status : Elementary School

Identitas pengantar pasien

Name
: Mr. N
Age
: 33 years old
Sex
: male
Address : Tanggulangi, Kebumen
Job
: social service
Marital status : married
Ethnicity : Javanese
Educational status : D3
Relation : Social Service

Alloanamnesis and Autoanamnesis

Main complain

Wondering and rampage in the street

History of present illness:
Patient was brought to RSJS by Social service due to wondering, laughing,
giggling, talk to herself, and rampage and angry without any reason in t
he street and disturb neighboorhood. Patient is very sure that she is the
big leader and king of the entire world, who is rule, lead, and command
people all around the world, and could know everythings what people d
oing, and she proud of herself, sure that all of prophet are her employee
d. Patient always hear sounds that always praised her, and she is so sure
thats came from her people. Patient is sure that she is always get wahy
u directly from the God, enter to her mind. Patient is sure that she has b
een live for 500 centuries. Patient always feel happy and proud to herself
because she is the most powerfull woman in the world.
According to information from social service, she started looks abnormal sin
ce 3 years ago. She often looks sad, pull herself from social interaction, q
uit from her work as farmer and has tendency to kill herself. But recently,
she show symptomps oppositely than before.
Her family were so shame and could not hold any longer to deal with her c
ondition and started to ignore her.

History of Past Illness

Psychiatric

illness
There is no history of pcychiatric illness.
General medical illness
There is no history of high fever, seizure,
head trauma, or any other serious illness
which needs hospitalization
Substance abuse
There is no history about alcohol use, dr
ug abuse or smoking .

Progression of Illness
Symptoms

2011

Role
Function

Feb2015

Family History
There

is no history of psychiatric illn

ess in her family.
There is no history of high fever, seiz
ure, head trauma, or any other serio
us illness which needs hospitalizatio
n

GENOGRAM

History of Personal Life

Prenatal

and perinatal
There was no valid data in patients pren
atal and perinatal aspect, such as :
Patients mothers age and condition w
hen she was pregnant
Patients mothers delivery history and p
atients perinatal condition.
Patients immunization status

History of Personal Life

Early childhood phase (0-3 years old)

Psychomotor
There was no valid data in patients psychomotor aspect (such as tilting the body,
supine to prone, sitting, standing, walking, smiling, holding her own hand, scoop
up object, holding pencil and pilling up two objects)
Psychosocial
There was no valid data in patients psychosocial aspect (such as replying to smile,
smiling when seeing interesting object, playing cilukba, knowing her family memb
ers and pointing what she wanted without crying)
Communication
There was no valid data in patients communication aspect (such as bubbling, cooi
ng, making sounds without meaning, telling 2-3 syllables without meaning and c
alling mama/papa)
Emotion
There no valid data in patients emotion aspect (such as when patient playing, frig
htened by strangers, starting to show jealousy or competitiveness towards other,
and toilet training)
Patient didnt pee or defecate in her pants when she was two years old
Cognitive
There was no valid data in patients cognitive aspect (such as copying sounds that

History of Personal Life

Intermediate childhood phase (3-11 years old)

Psychomotor

No valid data on when patients first time pl

aying hide and seek or if patient ever involve
d in any kind of sports.

Psychosocial
No valid data

Communication
No valid data

Emotion
No valid data

Cognitive
No valid data.

History of Personal Life

Late childhood and teenage phase (11-18 years old)

Psychomotor

No valid data if patient had any favorite hobbies or g

ames, if patient involved in any kind of sports.

Psychosocial
No valid data
Communication
No valid data

Emotion
No valid data

Cognitive
After graduating from elementary school, patient di
d not go to school anymore

History of Personal Life

Adulthood phase (18 years old-now)

Educational
Patient graduated from elementary school

Occupational
Patient had housewife.

Marital status
Patient has got married.

Criminal

She has no criminal history

Social activity

Patient was a resident of pondok pesantren and s

ometimes interated with other resident.
Current situation

Patient live alone.

Eriksons stages of psychosocial development

Stage

Basic Conflict

Important Events

Trust vs mistrust

Feeding

Autonomy vs shame
and doubt

Toilet training

Initiative vs guilt

Exploration

Industry vs inferiority

School

Adolescence
(12-18 years)

Identity vs role
confusion

Social relationships

Young Adulthood
(19-40 years)

Intimacy vs
isolation

Relationship

Middle adulthood
(40-65 years)

Generativity vs
stagnation

Work and
parenthood

Ego integrity vs despair

Reflection on life

Infancy
(birth to 18 months)
Early childhood
(2-3 years)
Preschool
(3-5 years)
School age
(6-11 years)

Maturity
(65- death)

General physical examination

General appearance :
she looks in good status

Vital sign

BP : 130/85 mmHg
HR : 118x/m
to : afebris
RR: 24x/m

General physical examination

Head

normocephali, mouth deviation (-)

anemic conjungtiva (-), icteric sclera (-), pupil isocore

Neck

: normal, no rigidity, no palpable lymph nodes

Thorax :
Cor : S1 S2 regular, murmur -, gallop

Lung

: vesicular sound +/+, wheezing -/-, ronchi-/-

Abdomen

flat, abdominal wall//chest wall, normal peristaltic, tympany sound, t

enderness -, mass -, liver, spleen and kidney not papable

Extremity

: Warm acral, capp refill <2, edema (-)

Neurological examination
Level

of Consciousness :

compos mentis, E4V5M6 (15)

General

Appearance :

Body posture : normal

Abnormal movement : Walking style : normal

Neurological examination
Cranial nerves

examination:
CN I : in normal finding
CN II
CN
CN
CN
CN
CN
CN
CN
CN

: in
III,IV,VI
V
: in
VII : in
VIII : in
IX
: in
X
: in
XI
: in
XII : in

normal finding
: in normal finding
normal finding
normal finding
normal finding
normal finding
normal finding
normal finding
normal finding

Motoric
Upper extremities: tonus (+), trophy :
eutrophic, power of movement : shou
lder joint : 5, elbow joint : 5, wrist joi
nt : 5, radial nerve function : 5, ulnar
nerve function : 5, median nerve func
tion : 5
Lower extremities: tonus (+), trophy :
eutrophic, power of movement : hip j
oint : 5, knee joint : 5, ankle joint : 5

Sensorium
DCML system : proprioception, fine to
uch : no abnormalities
AL system : vibration, temperature, cr
ude touch, pain : no abnormalities

Neurological examination
Physiological

reflex

Upper extremities: biceps reflex (+), triceps reflex (+), brachio

radial (+)
Lower extremities: patella reflex (+), achilles tendon reflex (+)
Pathological

reflex

Upper extremities: Hoffman (-), Tromner (-)

Lower extremities: babinski (-), chaddok (-),gordon (-),oppen
heim (-), rossolimo (-), clonus -/Meningeal

sign

Neck stiffness (-), brudzinski neck sign (-), brudzinski contrala

teral leg sign (-), kernig sign (-)
Cerebellum

function

Adhyadokokinesia (-), romberg test (-), finger to nose test (n

o abnormalities), tip to toe walk (no abnormalities)

Patient was brought RSJS due to wondering, laughing, giggling, talk to herself,
and rampage and angry without any reason and disturb neighboorhood.
Symptom:

Wondering,laughing,
giggling, talk to herself
Rampage and angry with
no reason
Patient is very sure that
she is the big leader and
king of entire world. Rule,
lead, and command people
all around the world
Could know what everyone
thinking and doing
Proud of herself, sure that
all of prophets are her
employeed
Always her sound that
praised her all the time
She is always get wahyu
directly from the God
She is sure that she has
been live for 500 centuries

Mental Status:

Behavior :
Hyperactive,
psychomotor
agitation
Mood : Euphoria
Affect : Broad
Progression of
Thought: Logorrhea.
Circumstantiality,
neologisme, flight of
idea
Hallucination :
Auditory (hearing
sound that praised
her)
Content of thought :
tought of insertion,
Delusion of
Grandiouse
Form of thought :
non realistic

Impairment:
Patient cant
work
Limied social
interaction
Poor self
grooming
Disturb
neighboorhood

SYNDROME
Thought of Broadcasting
Auditorik Halusination
Delusion of mistic power

Delusion of Grandious
Mood Euphoria
Hyperactive
Lack of sleep
Logorrhea
Flight of idea

Schizophrenia
syndrome

Manic syndrome

Differential Diagnosis

Skizoafektif tipe manik

F20.3 Skizofrenia katatonik
F25.0

Multiaxial Diagnosis
Axis I: F25.0 Skizoafektif tipe manik
Axis II

:
Axis III :
Axis IV :
Axis V :

R46.8 Delayed diagnosis

No diagnose
Poor family support
GAF admission 20-11

Patients problems
Biological

problem

Positive symptoms because of an increas

e in dopamine amount in the post synap
tic neuron
Psychological

problems

unclear
Social

problem

She cant socialize well with others

PLANNING MANAGEMENT

Management Planning
Hospitalization

Patient was hospitalized because

Patient was brought to RSJS by Social service due to wonderin
g, laughing, giggling, talk to herself.
Rampage and angry without any reason in the street and dist
urb neighboorhood.

Emergency Department
Inj. Haloperidol 5 mg 1 Amp IM
Inj. Diazepam 5 mg 1 Amp IV
Suggest ECT

Response Phase
Target Therapy
50% decrease of symptoms
Maintenance Therapy
Haloperidol tab 5mg 2x1
Chlorpromazine 100 mg 2x1
Diazepam 5 mg 1x1
Lithium 300mg 3x1

Remission phase
Target therapy :

100% remission of symptom

Inpatient
Haloperidol tab 5mg 2x1
Chlorpromazine 100 mg 2x1
Diazepam 5 mg 1x1
Lithium 300mg 3x1
Outpatient

Continue the farmacotherarpy

Psychoterapy : Supportive therapy and assertive community therapy
Interpersonal and Social Rhytm therapy (IPSRT)
Family focused therapy

Psychotherapy
Steps:
Assessment
Determine the goal
Methods
End session
How many session? Depend on the burden of problem itself
Factors:
Goal
Clients desire to recover
Experience and skills
Methods

Methods:
Psychoanalysis and Psychodinamic
Behavior Therapy
Cognitive therapy
Humanistic therapy
Holistic therapy

Recovery Phase
Continue

the medication, control to psychiatrist

Rehabilitation :

- Consult to psychologist to help patient fi

nding a hobby
- Help patient to interact normally with he
r family and neighbor

Family Education
Explain

to the family that anyone could have mental dis

orders
Mental disorders are caused by multifactorial factor, no
t only by genetic inheritance
Mental disorders mostly are affected by chemical imbal
ance in brain
Mental disorders can be controlled by medicines, so it i
s important to take the medicines routinely
Treat patient like you treat any other people
Help patient if she should be helped
Dont push patient to understand the family, but her fa
mily that has to understand her
Dont be too emotional to patient