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Bed Side Teaching

Bipolar Affective Disorder at Present Manic Episode with Psychotic Symptom

OLEH:

REDO AGUSTA

P. 1794 B

FAJAR DEFIAN PUTRA

P. 1801 B

KEVIN MAULANDA

P. 1812 B

PEMBIMBING:
dr. YaslindaYaunin, Sp.KJ

BAGIAN PSIKIATRI
FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS
RSUP DR. M. DJAMIL PADANG
2016
1

CASE REPORT
A 66 years old male patient was brought by his family from psychiatry polyclinic to the
psychiatrys ward of RSUP Dr. M. Djamil Padang on April, 14 2016 at 5.13 am
I.

IDENTITY OF PASIENT

Name

Mr. O

Sex

Male

Age

66 years old

Place and date of birth

Koto Pinai, October 10th 1949

Marriage status

Married

Religion

Moeslim

Occupation/School

Coconut farmer

Citizen

Indonesian

Tribe

Minangnese

Address

Jalan Koto Pinai Kenagarian Air Haji, Pesisir Selatan

II.

HISTORY OF PSYCHIATRIC

The data was taken from

Autoanamnesis with patient in psychiatrys ward at RSUP Dr. M Djamil Padang on


April, 20th 2016 at 4.13 pm

Alloanamnesis with Mr. E/ 25 years old/ live at same place with patient (biological son)/
at Padang on April, 20th 2016 at 4.45 pm

A. Chief Complain
Patient got angry and rowdy since 15 days ago.
B. Main Reason
Patient got angry, rowdy and tried to hit people surrounding him. Patient also threw
goods to other people since 10 days ago.
C. History of Present Illness
-

The patient got angry, rowdy and tried to hit people surrounding him. Patient also
threw goods to other people since 10 days ago. The patient got angry because his son
tried to unpack his own huts door for replacing his sons cowsheds.
2

He tried to hit people because he thought that other people was gossiping him. He
couldnt stop himself from it because he felt that his mind was full, so that he
wreaked it by hitting others.

He felt being controlled when he got angry.

He also felt suspicious with other people and thought that they tried to put ghost into
his body.

He smelled kemenyan smell 15 days before his admission until he came to the
hospital. After inpatient, the smell was absent.

He didnt obey the schedule to take medications during his time in home. Patient felt
that the medications taken were too big and not the same with the medications he got
from the hospital

He has been smoking for more than 40 years, approximately 2 packs per day.

There is no history of head injury, neurological, metabolic, infection problems and


other associated organ failure.

There is no history of consuming narcotics and other addictive drugs.

He didnt lose appetite, never feel sad. Sleeping time was adequate. There is no
withdrawal acts from society.

The patient didnt feel any fear of being in the crowd, of being humiliated by the
crowded people, of something that actually it never happens.

Patient has been hospitalized 2 times in 1998 and 2012.

D. Past Medical History


1. History of Psychiatric Disorder
a. In 1998
In 1998, patient was brought to the psychiatrys ward because he got angry and
rowdy. He saw ghost shadow and heard whispers of ghost that asked him to scold
his son. He was suspicious that the ghost was sent by his cousin due to his
cousins envy. He was hospitalized for 2 months in RSUP Dr. M. Djamil. He
went home after doctors allowance. He took medications regularly for 8 years (he
remembered how many types, but forgot the name and color), but after that he
didnt take the medications regularly anymore because his family thought that he
had recovered.
3

b. In 2012
In 2012, he got angry and rowdy with his sons act. His son was unpacking the
doo, but the patient thought that his sons act was useless and no reason. He also
often talked alone when people was not around him. He was hospitalized for 22
days in RSUP Dr. M. Djamil. He went home after doctors allowance. He took
medications regularly (he remembered how many types, but forgot the name and
color).
2. History of Medical Disorders
There is no history of head injury, neurological, metabolic, infection problems and
other associated organ failure
3. History of Consuming Alcohol and Other Addictive Substances
The patient has been smoking for more than 40 years ago, 2 packs per day. There is
no history of consuming narcotics and other addictive drugs.
4. History of Personal Life
a. Perinatal and prenatal
The partus process was normal, the baby was mature, health condition during
pregnancy was good, the emotion during pregnancy was good. During pregnancy
the mother didnt consume any kind of drugs.
b. Early child period
Patients growth and development were normal and same with other kids. There is
no history of behavior disorder in this period.
c. Mild child period
There is no learning disorder. Social interaction is normal. Patients growth and
development wee normal and same with other kids. Patient had many friends.
d. Late children and teenager
There is no history of psychosexual disorder.
e. Adult period
-

Educational Background
Patient only studied until 2nd year of elementary school.

Occupational Background
4

Patient is now working as a cocounut farmer in Air Haji.


-

Marriage History
Patient has married with his wife since 1976.

Religion History
Patient knew know well about Islam. He was quite routine in doing prayers.

Psychosexual History
There is no history of sexual abuse or sexual disorientation.

Social Activity
In some time, the patient easily to get along, others so irritable cheerful. In
other condition patient dont want to have communication to others.

Lawlessness History
There is no history of lawlessness, criminal issue, and arrested

E. Family History

Description:
= Pasien

= Pria

= Wanita

= Live at same place


5

There were no family members that has same symptoms of this mental disorder

F. Current life situation


Now the patient lives with her wife and the family of. Siblings of patients lived next door
to the patient's residence. The house is belong to the patient and wife. Living cost borne
by the patient itself. The patient and her wife have doesnt have an account. patient earn
some money around 1.000.000 rupias permonth. From this money patient and her
husband fulfill needs out side of the daily needs.

G. Family Perceptions and expectations


Family hopes that patient recovers soon

III.

INTERNAL STATUS

General condition

Awareness

: Composmentis

Blood pressure

: 120/70 mmHg

Pulse

: palpable, regular, 86 times per minute,

Respiration

: abdominothoracal, regular, 20 times per minute

Temperature

: 36,80C

Height

: 168 cm

Weight

: 58 kg

Nutritional status

: normoweight

Cardiovascular system :
Inspection

: ictus cordis not seen

Palpatiom

: ictus palpable around one finger medial to left midclavicular line,


5th intercostal space

Percussion

: up : 2nd intercostal space, left : one finger medial to the left


Midclavicular line, right : dextra sternalis line

Auscultation

: normal and regular heart sound. Murmur is absent


6

Respiratory System

Inspection

: simetris statiscally and dinamically

Palpation

: fremitus similar between left and right chest

Percussion

: sonor all over the thorax

Auscultation

: vesicular breath sound present, ronki is absent, wheezing is absent

Specific abnormalities : none

IV.

NEUROLOGICAL STATUS

GCS

: 15 (E4M6V5)

Meningeal Signs

: None

Ekstrapiramidal sign
- Hand tremor

: absent

- Akatisia

: absent

- Bradikinesia

: absent

- Way of stepping

: normogait

- Balance

: not disturbed

- Rigiditas

: absent

- Power

: 555 555
555 555

- Motoric

: freely in any direction

- sensorik

: well propiosptif and exteroseptif


on of patient

V.

MENTAL STATUS

Autoanamnesa
Questions

Answers

Assalamualaikum pak

Waalaikum salam

Pak, ambo Redo, kawan Buliah...

Interprestation

Composmentis

ambo ko fajar, dan kevin,


7

kami dokter muda disiko,


buliah awak tanyo-tanyo
saketek pak?
Namo apak sia pak ?

Oden
Personal orientation intact

Lah bara umua pak?

66 tahun

Tahun bara tu berarti pak?

19

Apak tau kini sedang dima Di

Padang,

Dr.M.Djamil padang

Hari apo kini pak ?

Selasa

Tahun bara kini pak

2015

RSUP

Time

and

place

orientation is disturbed

Bulan a kini pak? 3,4 atau 5 3


Apak kan di aia aji kan dari Jauah painan lai
aia aji, ma yang lebiah
jauah tarusan dar pado
painan
Jo sia apak kamari?

Rami-rami samo oto

Baa kok apak kamari?

Dibaok keluarga

Ado apak berang-berang di Ado awak berang-berang se,


rumah ?
Emang

perasaan gelisah lo
apo

sampai

Behaviour disorder

masalahnyo Yo anak ambo nyo tanggaan

mabuek

apak pintu rumah awak untuak

berang-berang?

kandang jawinyo

Anak apak se yang apak Ado urang-sekitar awak


berangan atau ado urang
lain yang apak berangan
Dek a tu? Sampai apak Iyo awak tokoknyo, awak
tokoknyo?

berangan dek gara-gara raso


dalam pikiran awak urang-

Thought disorder

urang tu mangecek an awak


8

dan raso-rasonyo beberapa


urang mancubo mamasuak an
setan ka dalam tubuh awak
Ndk bisa apak tahan berang Ndk, dek banyak bana raso
apak tu

pikiran awak, ndk mampu wak


tahan lai

Pas

apak

berang

dan Tau dok, tapi baa lah awak

manokok urang tu, tau ndak maaraso awak ndak salah kan
itu perilaku yang salah, tu urang-urang tu nan salah ma,
pas berang-berang tu a nan pas berang-berang tu awak
taraso dek apak

maraso di kendalikan oleh


setan pak

Apak tau sia presiden wak jokowi

Allenged level

kini?

intelligency good

Lah acok di rawat siko pak

Iko lah yang ka tigo di rawat


di siko

Not the first syptom

Tahun bara-bara se tu pak, 1998-2012-2016


yang apak ingek se
Lalok

baa pak, jam bara Lalok lamak dok, lalok jam 10

lalok pak, tu jam bara jago jam 4 lai lamak tasonyo


tajago,

dan

lai

lamak pak

rasonyo pak?
Kini baa perasaan apak?

Ndak ado taraso apo-apo do.

Discriminative insight is
disturbed

Yang lain apo nan apak Iyo, itu se nyo


rasoan?
Kalau

itu,

mandanga

ado

apak Ndak ado pak

bisiak-bisiakan

buk?padohal

ndak

ado

Halusinasi auditorik (-)

urangnyo buk?
Ooo...kalau

mancaliak- Ndak ado pak

Halusinasi visual (-)


9

caliak hantu, atau bayangan


bayangan?
Mancium

bau-bauan?bau

harum kayang kemenyan Kalau baun baunan ado pak


gitu atau bau busuak, tapi taraso baun kemenyan

Halusinasi olfaktorik (+)

ndak ado sabananyo doh


Jam bara tarasonyo tu pak Malam dok, alah 15 hari pas
pagi atau malam dan alah siko ilang. Kareh baunnya dok
bara lamo, tu kareh ndak
baunyo
Ado

apak

cameh-cameh Ndak ado doh

balabiahan?

Berdebar-

No anxiety

debar?
Ado apak maraso sadiah Ndak ado do
akhir-akhir ko ?
Ado apak maraso bersalah Ndak ado do
?

No depression

Ado apak bapikia kalau Ndak ado do


iduik ibuk ndak baguno lai
?
Ado apak maraso dendam Ndak ado do
atau banci ka urang lain

Animocity/ revenge (-)

buk ?
Pernah apak maraso ndak Ndak ado do
baguno ?

Inferior feeling (-)

Kalau ado kabakaran disiko Ambil air siram api jo air

Discriminative judgement

apo yang ibuk lakukan ?

is not disturbed

Persamaan kudo jo jawi Samo-samo binatang


apo buk?
Siap

pulang

beko

Abstract thinking is good

nio Ubek tu gadang bana buk Abulia (+)


10

manga ibuk dirumah ?

maleh wak makannyo

Ibuk ado pakai obat-obatan ndak ado doh


buk dari dokter?
Maaf sabalumnyo buk,Ibuk ndak ado doh
pernah

sebelumnya

manggunoan narkoba buk?


Sakik yang lain ado buk?, Ndak ado doh
sakik kapalo?paruik sakik?
Iyo lah buk, tarimo kasih Iyo samo samo dok
banyak yo buk
Based on the examination in April, 20th 2016
I. General Conditions
Consciousness/sensorial

composmentis/good

Attitude

cooperative

Motoric behaviour

hyperactive

Facial expression

rich

Verbalization

speak clearly

Psychical contact

could be done / proper enough / long enough

Attention

good enough

Initiative

good enough

II. Specific condition


A. Affective
1. Affective condition

hiperthym

2. Emotional :
a. Stability

labil

b. Control

not good enough

c. Echt/unecht

echt

d. Einfuhlung

inadequate
11

e. Deep/shallow

shallow

f. Differentiation scale

narrow

g. Emotional flow

fast

a. Memory

less

b. Concentration

disturbed

c. Orientation

disturbed

B. Intellectual condition of function

personal,

and

place

orientations.
d. General knowledge

difficult in value

e. Allenged level intelligency :

good

f. Discriminative insight

level 1

g. Discriminative judgment

good

h. Intellectual decreasing

none

C. Sensation and perception abnormalities


1. Illusion

: none

2. Hallucination

Acoustic

: none

Visual

: none

Olfactory

: yes

Tactile

: none

Gustatory

: none

D. Thought process condition


1.

Speed of thought processs

fast

2.

Quality of thought process:


a. Clearness and sharpness

clear enough and sharp enough

b. Circumstantial

none

c. Incoherent

none

d. Sperrung

none
12

none

f. Flight of ideas

none

g. Verbigeration

none

h. Preservation

none

a. Central pattern

none

b. Phobia

none

c. Obsession

none

d. Suspicion

none

e. Delusion

none

f. Confabulation

none

g. Dominance, animosity

yes

h. Inferior feeling

none

i. Much / little

much

j. Guilty feeling

none

k. Hypochondria

none

l. Others

none

3.

e. Hemmung

Thought condition

E. Instinctual impulse and behavior abnormalities


a. Abulia

none

b. Stupor

none

c. Raptus/impulsivity

none

d. Excitement state

yes

e. Sexual deviation

none

f. Echopraxia

none

g. Vagabondage

none

h. Pyromania

none

i. Mannerism

none

j. Others

none
13

F. Over anxiety

none

G. Reality testing ability

behavior, thought, disturbed feeling

VI. MULTIAXIAL EVALUATION


A. Axis I (Clinical syndrome)
Based on anamnesis, the history of clinical course of this patient was founded that
there is significant changes in behavior pattern and feeling clinically and it causes disability in
function, working and social. Therefore, based on PPDGJ III, it can be concluded that the patient
have mental disorder.
From chief complain and main reason that obtained from patient himself and his
family, it can be concluded that the patient had several signs; irritable, olfactoric hallucination,
supposition. And from the onset and episode of symptoms obatained, it seems there was a phase
where the patient has been fully recovered, and after a long treatment, the family felt that the
patient was fully recovered, they stopped the medications, and the symptoms came again. That is
the point why we diagnose this patient with bipolar affective disorder (F31).
There is also no history of head injury, neurological, metabolic, infection
problems and other associated organ failure. So it can get rid of organic mental disorders (FF00
F09). Furthermore, there is also no history of consuming narcotics and addictive drugs, so that
there is no retaltionship with mental and attitude disorder due to psychoactive drugs
consumpstion (F10-F19). He also didnt lose appetite, never feel sad. Sleeping time was
adequate. There is no withdrawal acts from society. It means there is no sign that can be
connected to depressive episode (F32). And also the patient didnt feel any fear of being in the
crowd, of being humiliated by the crowded people, of something that actually it never happens. It
means there is no sign that can be connected to anxiety disorders (F40-48). That is why we
conclude the diagnosis of this patient is Bipolar Affective Disorder at Present Manic Episode
with Psychotic Symptom (F31.2)

B. Axis II
Based on personality history, there is no personality and mental disorder on patient founded
yet.
14

C. Axis III
There is no another medical problem with this patient.
D. Axis IV
There are problem with primary support group.
E. Axis V
The patient had mild symptom and settle, mild disability in funtion, and overall still good in
general, so the GAF score was 70-61
VII.

MULTIAXIAL DIAGNOSIS

I.

F31.2 Bipolar Affective Disorder at Present Manic Episode with Psychotic Symptom

II.

No diagnosis yet

III.

No diagnosis

IV.

There are problem with primary support group

V.

GAF 40-31

VIII. DIFFERENTIAL DIAGNOSIS


F31. 6 Bipolar Affective Disorder at Present Mixed Episode
F31.8 Other Bipolar Affective Disorders
F25.0 Manic-type Schizoaffective

IX. THERAPY
A. Pharmacotherapy
-

Risperidon 2 x 2 mg

Merlopam 1 x 0,5 mg

Haloperidol 1 x 1,5 mg

Vit B complex 3 x 1

Vit C 3 x 1
15

B. Psycotherapy
1.Patient
- Support psycotherapy
- Psychoeducation
- Pharmacotherapy
2. Family : Psychoeducation about patient condition and histherapy
X. PROGNOSIS
Point

Good

Not good

Onset

Adult

Onset of time

Not clear

Family Support

Not good

Marital status

Married

Positive symptom

Exist

Symptom of mood Depression and manic

disorder
Precipitating factor

Clear

Sosial withdraw

Exist

neurologis Exist

Many relaps episode

Exist

Others disease

None

Sign
disorder

Quo ad Vitam Clinical

bonam

Quo ad Functionam

dubia et bonam

Quo ad Sanationam

dubia et bonam

16