BIPOLAR AFFECTIVE DISORDER

BY:
Dion Pratama
Rahmat N. Yuda Putra

Preseptor:
Dr. Yaslinda Yaunin, Sp. KJ

CASE REPORT SESSION

 Patient Identity

Name : Mr. RA
Gender : Male
Age ` : 23 years old.
Marital status : Single
Address : Sungai Sapih, Padang,
West Sumatera
Occupation and School : Work as goat milker / SMK
Religion : Islam
Citizen : Indonesian
Race : Minangkabau
ANAMNESES
A male patient 23 years old come to Poli Jiwa RSUP
DR. M. DJAMIL Padang by himself on September 8th
2015 with the symptom is reguler control.
Main reason of Medical Check-up

Medical control for every month

History of Present Medical Condition

In the month of September 2015, he came to the

Psychiatry Policlinic and asking for advice, sharing his
life story, and asking for drugs because it make him
easier to control his temper.
History of Medical Condition
Year 2001 : Parental Divorce 9 Years old feels
sadness and sorrow his dad hadnt take the
responsibility to take care of his family patient often
pondering and pull himself from society
Year 2007 : Irritable and angry to his friends for
mocking him He chased them and took ceramic as a
weapon They were taken to Counseling Teacher and
given advice to doctor Psychiatric Policlinic doctor
ordered him to control his medication for every month
Year 2011 : Senior High School National Exam was
near started to think about his future and his partner
for life, still mocked by his friends and neighborhood.
He felt more irritable again angry with his
neighborhood they was singing loudly in night time
Premorbid History
Infant : born spontaneously, birth was assisted
by midwife, no history of jaundice, cyanosis, or
seizure.
Childhood: growth and development suitable for his
age.
Adolescence : patient have few friends, but
prefer to stay at home rather than being outside
Adult : patient have few friends, but prefer to
stay at home rather than being outside
 Educational Background
Educated till third year of senior high school.
Work history

Working as a goat milker and earned Rp 400.000

per month
Marital status

Patient is single
Socio economic status

Patient lived with his family : his mother, 1 brother

and 1 sister, permanent house, there is water source
from PDAM, there is electricity, they can pay all
they needed.
Family History
One of patients sister has the same symptoms as
him
Graphic of Illness Course
Physical Examination
Internal Status
General appearance : Compos Mentis
Blood pressure : 120/70 mmHg
Pulse rate : 82 x per minute
Respiratory rate : 19 x per minute
Temperature : 36,7 oC
Cardiovascular system : No disorder found
Digestive system : No disorder found
Specific disorder : No disorder found
Neurological Status
GCS 15, pupil reflex positive, corneal reflex
positive
Cranial nerves normal, Meningeal Signs (-),
Increased Intercranial Pressure (-)
Eyes : No disorder was found
Motoric : Eutonus, muscle strenght normal, no
tremor
Sensibility : No disorder was found
Spesific Disorder : No
 General Appearance
Counciousness : compos mentis
Attitude : cooperative
Motoric : active
Facial expression : rich of facial expression,
Verbalization : can talk, clearly
Physic contact : can be done, proper, long time
Attention : good
Initiative : good
Spesific Condition
Affective
Affective condition : hipertym
Emotional
Stability : stable
Control : controlled
Echt/unecht : echt
Einfuhlung : adequate
Deep/shallow : deep
Differentiation scale : wide
Emotional flow : fast
Intellectual condition of function

Memory : good
Concentration : good
Orientation : time, place, situation,
and person orientation is not disturbed
Knowledge : normal, average
Discriminative insight : not disturbed
Intelligence prediction : normal, average
Discriminative judgment : not disturbed
Intellectual condition of function
Sensation and Preception Abnormalities : Illusion
(-) Hallucination (-)

Speed of thought process : fast

Quality of thought process : Clear and sharp,

no disabilities

Thought condition : No disorders or disabilities

Instinctual drive and behavior
abnormalities
No abulia, raptus, stupor, exicitement state, sexual
deviation and other symptoms

Overt Anxiety : None

Reality Testing Ability : good in behavior, thoughts,

and feeling
Other Examination

Social Evaluation by social expert : Not yet

Psychological Evaluation by Psychologist : Yes, 8
September 2015
Other Evaluation : Not yet
Supporting Examination : Not yet
FORMULATION OF DIAGNOSE
Changes of behavior pattern and affect that clinically
significant and disability in social function
Psychology disorder
Patient never had any injury in head, and other disease
that physiologically can make psychology disorder
Organic mental disorder can be excluded (F.00-09)
No history of drug abuse Behavior and mental
disorder caused by psychoactive agent can be
excluded (F.10-19)
Some episode of depression followed by manic
episode. Those episodes happened for several days
Bipolar Affective Disorder, current episode hypomanic
 Patient didnt have any personality disorder and
there is no mental retardation no diagnose for
AXIS II

Patient have some problem with his social

environment, he was a victim of bullying and
parental divorce problem with his primary
support group and his social environment for AXIS
IV

There was a little disability in his working ability

and the symptom didnt disturb his work ethic and
he can overcome his disability and work as usual
Global Assesment of Functional scale was
scored 80-71
MULTIPLE AXIS RESUME

Axis 1.
Clinical syndrome

Patient have unstable mood began at 2001. Got

medication from psychiatry policlinic at Dr. M.
Djamil General Hospital Padang at 2007, and do
the control regulerly.
In 2011, he had National High School Exam and
thinking about his future, so he felt sad again.
At the same year, he feels irritable again and
angry to his neighborhood caused by singing loudly
at night.
 Psychiatric examination
General condition: compos mentis, cooperative,
active, rich of facial expression, verbalization is can
talk and clearly, good attention, good initiative,
psychic contact can be done, proper, long time.

Specific condition :
Affective condition : hipertym, stable, echt, deep,
wide, fast
Intellectual condition of function : good memory,
good concentration, time, place, situation, and
person orientation is not disturbed, knowledge is
normal-average, discriminative insight and
judgments is not disturbed.
 Sensation and perception abnormalities : no illusion,
no hallusinasion (auditory, visual, olfactory, and
tactile).
Thought process condition : clearly and sharp,
coherent
Instinctual drive and behavior abnormalities : none
Over anxiety : none
Reality testing ability : good in behavior,
thoughts, and feeling

Axis II. Personal disorder and mental retardation

disorder
Personality disorder : none
Mental disorder : none
Axis III. No diagnose

Axis IV. Problem with primary support group and

social environment.

Axis V. Global assessment functional

Social : little disturbance
Daily Activity : no disturbance.
Leisure/ recreational activity : no disturbance
Multiple Axis diagnosis
I . F.31.0 Bipolar Affective Disorder, current
episode hypomanic
II. No Diagnosis

III. No Diagnosis

IV. Problem with primary group support

V. GAF: 80 - 71

Differential diagnosis
F 31.1 Bipolar Affective Disorder, current
episode manic, without psychotic symptoms
F 31.6 Bipolar Affective Disorder, current
episode mixed
 Therapy
R/ Olanzapine 4 mg
Thiamin 2 mg
Piridoxine 2 mg
Mf pulv dtd No. XXX
S1dd caps I
Psychotherapy

For Patient

Supportive psychotherapy
Psychoeducation

For Family
Psychoeducation about patient
disorder
Prognosis

Clinical : bonam
Functional : bonam
Social : dubia at bonam
Case Analysist / Conclusion
The patient diagnose was found from patient medical history,
there was repeated changes of mood from 2001 until now.
Patient was talking too much, hipertym, echt, and fast
emotional flow. Patient was diagnosed with Bipolar Affective
Disorder, current episode hypomanic (F31.0), Patient was given
Olanzapine 4 mg, Tiamin 2 mg, and Piridoxine 2 mg, and
mixed into capsule. The medicine must be taken one per day in
night time.