Bed Side Teaching

Bipolar Affective Disorder Manic Phase with Psychotic Symptoms

By: Yusnida Rahmawati Siti Masyita Putri Utami P. 1117 P. 1119

Preceptor: dr. Yaslinda Yaunin, Sp.KJ

Psychiatry Department Medical Faculty of Andalas University RSJ Prof. HB Saanin Padang 2013

Case Presentation A 30 years old man was admitted to HB Saanin asylums emergency unit on March 26th, 2013 at 9.00 p.m and escorted by his mother. This patient was permitted to hospitalize by dr. Wiwi Patient identity: Name and Age MR Gender Place and date of birth Marital status Address Occupation/School : : : : : : : Mr. B/ 30 years old 014108 Male. Padang, July 23rd 1973 Married Anggur III street, number 167, Kuranji, Padang Employer of Bumi Minangs Hotel/ Diploma I of Hotel Management Religion Citizen Tribe : : : Islam Indonesian Minangnese

A. Internal Status (April 1st 2013) General appearance Blood pressure Pulse Respiration Temperature Body Shape Height Weight : Compos Mentis : 110/70 mmHg : Easily palpable, regular, 85x per minute, : Abdominotorakal pattern, regular, 20x per minute : 36,70C : Athleticus : 170 cm : 75 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 Convergence Reaction : Free to all direction : No nystagmus, no diplopia : Round and isokor : +/+ : Not examined

Ophtalmoscopic examination : Not examined

Motoric Tonus Turgor Strength Coordination Reflex : Eutonus : Good : Good : Good : Physiologic (++/++), pathologic (-/-) : Smooth and rough sensation is good : Good appetite, sleep well : Reading, writing, drawing activities can be done well

Sensibility Vegetative Function Basic Function Specific disorder Rigid Tremor Nasal Stiffness

: None : Present (+1) : None

Oculogyric Crisis : None Torticolis Others : None : None

Autoanamnesis, April 1st 2013 : Questions Assalamualaikum Answers Waalaikumsalam Composmentis Cooperative Interpretation

Pak, kenalkan, Saya Ami. Dan Ndak ba a doh. Apo salahnyo.. saya Wati. Kami dokter muda. Awak bacarito-carito sabanta Duduk disitu wak lah (sambil menunjuk kursi) lai ndak ba a Pak? Siapo namo Bapak? Bara umur bapak? Bonik Hardi Menjelang 30 tahun, tanggal 23 Juli1973. Cubo takok hari a? Hari anak nasional, haha... (sambil tertawa) Di Padang. Dima wak kini ko dek ibuk? Di Rumah Sakik sijundai (Pasien bertanya dan menjawab sendiri pertanyaan nya sambil tertawa)

Temporal orientation is not disturbed

Iyo,Pak?.. Dima Bapak lahir?

Kalau namo rumah sakiknyo Rumah sakit Profesor Dokter apo Pak? HB Saanin. Bapak pernah dari Padang ke Pernah Bukittingi? Kalau dari Padang ke Menjebak pertanyaan ibuk Bukittingi, ma yang dulu mah.. tu yo Sicincin dulunyo. Sicincin dari pado Padang Panjang? Siapo namo presiden awak Susilo Bambang Yudoyono kini Pak? Partai apo yang menang Demokrat, warna biru PEMILU patang ko Pak? lambang partainyo. Biru laut samo biru langit.

Spatial orientation is not disturbed

Personal orientation is not disturbed Situasional orientation is not disturbed

Ba a kok dirawat Bapak di Dipaksa mama. Inyo siko? memanfaatkan PNS istri ambo. Awak ndak sakit badan doh, tapi jiwa se nyo.

Discriminative insight is not disturbed Suspicious

Kenapa dipaksa mama?

Ndak tahu doh

Ado bapak marah-marah ka Ndak ado wak marah-marah keluarga atau orang lain? doh. Awak saba se nyo. Seperti kata Mario Teguh, perasaan marah itu ibarat mengisi air di dalam gelas, semakin lama semakin penuh dan sampai meluap. Kalau sudah menumpuk banyak tentu persaan marah itu akan keluar. Lah shalat bapak? Shalat zhuhor alah tadi, ashar alun doh Badosolah awak jadinyo Discriminative Judgment is disturbed

Kalau ndak shalat ba a Pak?

Ado bapak mandanga suaro- Ado, katonyo Bun,ba a ang suaro yang orang lain ndak ko... bisa mandanganyo. Ibuk ingin kayo ndak? Tahu caronyo? Kato Deddy corbuzer ketik Reg spasi kaya kirim ke 9338 Sajak bilo bapak mandanga Sajak di rumah sampai dirawat suaro tu? di anggrek (4 hari yang lalu), Kini ndak ado tadanga suaro tu doh. Nampak bapak urangnyo? Ndak

Flight of ideas

Now : Auditoric Hallucination (-)

Visual Hallucination (-) Olfactorik Hallucination (-)

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Ado mencium bau busuk atau Ndak ado

harum Pak? Ado bapak merasa dipegang- Ndak ado pegangnyo? Bapak ado rasa takut dengan Takut tu ado di lagu ko. (Lalu sesuatu? pasien bernyanyi lagu minang yang adakata takutnya, setelah itu pasien tertawa) Ndak ado awak takut-takut doh. Bapak ado maraso pikiran Ndak ado bapak di baca orang lain? Bapak bisa membaca pikiran Ndak bisa. Tu Deddy orang lain ndak? Corbuzer yang bisa baca pikiran orang. Bapak ado merasa pikiran Ndak ado, haha,, bapak kosong atau disedot orang lain ? Ada bapak merasa jadi orang Ndak ado besar? Atau dipengaruhi oleh suatu kekuatan? Tactil Hallucination(-)

Circumstantial (+) Fobia (-)

Thought broadcasting (-)

Thought insertion (-)

Thought withdrawel (-)

Delusion (-)

Alloanamnesis: Allo-anamnesis was given by: Name Sex Age : Mrs. M : Female : 55 years old

Occupation : House wife Relationship with patient : Mother

Primary cause of hospitalization Patient restless, irritable, talkative, sometimes talk by himself since 2 days before hospitalized. Patient was hospitalized for for the third time. Present complain of patient There is no complaint at this time. History of illness: 2007 Patient was restless, not focused, listen the freaky voices, often angry without a reason to his family and sometimes talk by himself as though there was someone near him . His mother presumed he had any problems with his job because he often complained about his job. Moreover, his mother presumed that he possessed because he often did mountain climbing. Then, patient did ruqyah theraphy. Complaint of patient did not decrease. Then patient admitted to RS J HB. Saanin and treated for one month. Patient went home with good condition without restless. Patient was routinely controlled to the hospital and consumed medicine. 2008 The symptomps same with in 2007, plus prefered to talk by himself, change of attitude such as often stoop like elderly and sometimes talking like a child. His family did not know what triggers of his symptoms. Patient sought medical treatment to dr. Yaunin, Sp.KJ and finally hospitalized in RSJ HB Saanin. Patient went home with good condition without restless. Patient was routinely controlled to the hospital and consuming medicine. 2013 Patient married in 2012. March, 2013, his disease was relapse. Patient was restless, irritable, talkative, sometimes talk by himself. His mother presumed that he had the problems with his wife. He did not consume medicine since 7 days. He escorted by his mother to RSJ HB Saanin and treated. His wife did not know about that.
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Premorbid history Infant : born spontaneously, birth was assisted by midwife, no history of jaundice, cyanosis, and seizure. Childhood Adolescence : : growth and development according to his age. patient often angry without a reason

Educational background Elementary School at SD Kuranji, for 6 years Junior High School at SMP 28 Padang, for 3 years Senior High School at SMA 5 Padang, for 3 years. Graduated from Diploma I of Hotel Management School

Social economy history The patient worked as a waitress KFC in 2006. Then, in 2012 patients worked as a hotel employee. Patient's wife worked as a civil servant and marine fisheries service. Income was sufficient for their daily lives. Patients married in 2012, when his wife was 34-year-old, his wife often disagreed and quarreled with his mother. According to the patient's mother, lately revealed that his wife had mental illness, often angry especially to patients mother. Patients family and his wifes family relationships were less harmonious. Patients usually had good performance in the workplace and now becomes decrease. Patient had not a child and now seeking medication for it.

Family history of illness

There were no family members that has same symptoms like this.
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Graphic
Occupation Problem Problem ? Medicine withdrawal Household Problem

2007

2008

2013

EXPLANATION AND CONCLUSION OF PSYCHIATRIC EXAMINATION Examination is on April, 1st 2013, 2.30 p.m WIB 1. General appearance Consciousness/sensorial Attitude Motoric Facial expression Verbalization Physic contact Attention Initiative 2. Specific condition A. Affective 1. Affective condition 2. Emotional : a. Stability b. Control c. Echt/unecht d. Einfuhlung e. Deep/shallow f. Differentiation scale g. Emotional flow : stabil : good : echt : inadequat : shallow : wide : fast
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: : : : : : : :

compos mentis/good cooperative active rich speak clearly could be done / appropriate / long good good

: hypertim

B. Intellectual condition of function a. Memory b. Concentration c. Orientation : good : good : good

d. General and schooling knowledge : can not predicted e. Discriminative insight f. Intelligence prediction g. Discriminative judgment h. Intelectual deterioration : disturbed : average : none : none

C. Sensation and perception abnormalities 1. Illusion 2. Hallucination Acoustic : none : : present. Since 6 years ago, until 4 days ago, now, the acoustic hallucination is none Visual Olfactory Tactile Gustatory : none : none : 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 : : : : : : clear and sharp present none none none present
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fast

g. Verbigeration h. Preservation

: :

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 : : : : : : : : : : : : none none none none present none none none much present none none

E. Instinctual drive and behavior abnormalities a. Abulia b. Stupor c. Raptus/impulsivity d. Excitement state 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 none none none none disturb in feeling
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MULTIPLE AXIS RESUME Axis I. Clinical Syndrome Patient restless, irritable, talkative, sometimes talk by himself since 2 days before hospitalized. Patient was hospitalized for for the third time. Phsyciatric examination: General Appeareance: compos mentis, cooperative, active, rich, can speak clearly, psychic contact could be done, appropriate, long. Specific condition: a. Affective condition: hypertim, stabil, good, echt, inadequate, shallow, wide, fast. b. Intellectual condition and function: good memory, concentration is good, good orientation, absent intelectual deterioration, discriminative insight are disturbed, discriminative judgment is good. c. Sensation and perception abnormalities: no illusion, hallucination is present since 6 years ago until 4 days ago. Now, the acoustic hallucination is none. d. Thought process condition: fast, clear and sharp, central pattern none, delusion is absent, much, circumstancial, flight of ideas, suspicious of others is present. e. Instinctual drive and behavior abnormalities: none f. Overt anxiety: none g. Reality testing ability, disturbed: feeling

Axis II : Personality Disorder and Mental Retardation Disorders Personality: outgoing, has a lot of friend Mental retardation: none
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Axis III : General Medical Condition There is no capitis trauma, malaria, abdominalis thypoid history and other disease that need hopitalization. Axis IV : Phsychosocial Stressor and Environment Household Problems Medicine withdrawal Axis V: Global Assessment of Function Social relationship could be done Spending time with watching TV, travelling, could be done MULTIPLE AXIS DIAGNOSIS I. II. III. IV. V. F.31.2 Bipolar Affective Disorder Manic Phase with Psychotic Symptoms No Diagnosis. No Diagnosis. Problem with family, household problems and medicine withdrawal GAF 80 71

DIFFERENTIAL DIAGNOSIS I. F. 25 Skizo affective, manic type

THERAPY Risperidon 2x1 @ 2 mg Asam valproat 2x1 @ 250 mg Chlorpromazine 1x1 @ 100 mg (at night if need)

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PROGNOSIS Clinical Functional Social : : : dubia at bonam dubia at bonam dubia at bonam

SUGGESTION FOR THERAPY Education to the family

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