Bipolar Affective Disorder, Manic Episode With Psychotic

7/30/2019 Bipolar Affective Disorder, Manic Episode With Psychotic

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MUHAMAD AZRUL 0810314158CHARAN PAL SINGH 0810314156

PRECEPTOR:dr. YASLINDA YAUNIN SP. KJ


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Name : Sari Bulan Gender : Female Age ` : 29 years old. Marital status : single Address : koto Napan, Sumut Occupation and School : Secondary school,

not working Religion : Islam Citizen : Indonesian Race : Minangkabau


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A 29 year old female patient was admitted to RSJHB Saanin emergency department on April 26th,2013 and escorted by her brother. This patient

presented with signs such as anxiety, alwaysbeing angry without reason, always talking toherself without sense, laughs herself even whenthere is no one around, sometimes she becomes

emotional when things doesnt go on her needs..She has delusion of greatness and thinks she is afamous artist. She has no problem in her eatinghabits. She threatened her family members with

harsh words


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Internal Status

General appearance : Compos Mentis

Blood pressure : 110/70 mmHg

Pulse rate : 86 x per minute

Temperature : 36,5 C

Cardiovascular system : No disorders found

Digestive system : No disorder found

Specific disorder : No disorder found


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Neurological Status

GCS 15, pupil reflex positive, corneal reflex positive

No meningeal signs, no signs of increased intracranial pressure

Cranial nerves : No disorders found

Motoric : Eutonus, Eutrophic, no disorder,

Muscle strengthsuperior extremity 555/555,

inferior extremity 555/555

Sensibility : No disorder foundSpecific disorder : No disorder found


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ALLOANAMNESIS

Was done on 20th May 2013

Alloanamnesis obtained from patients brother:

Name : Salam

Age : 44 years

Telephone :

Work & Education : private company

Relation with patient : brother


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1.

Main reason of HospitalizationThis patient presented with signs such as anxiety, always being angry without reason,

always talking to herself without sense, laughs herself even when there is no one around,

sometimes she becomes emotional when things doesnt go on her needs.. She has

delusion of greatness and thinks she is an famous artist. She threatened her family

members with harsh words


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Present complaint of Illness

Patient classified as Healthy without any complaint

1. History of IllnessYear 2006 (Month unidentified)

Patient was frequently anxious; always get angry if her need doesnt go with her desire.Always goes out during the night, threaten her family members with harsh words and was

brought to the RSJ HB Saanin and was admitted


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Year 2007-2012 (month unidentified)

The patient was admitted regularly to the hospital for the same complaints She was

brought to RSJ HB Saanin and was warded there. She has been in and out of the hospital

for the past 6 years with the same complaints

Year 2013 (April till Present)

Patient does not want to take regular medications, laughs without any reason, she has

delusions of greatness as if she is a famous celebrity. The patient likes shopping. The patients

also thinks she has graduated from university and obtained a degree.


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3. Premorbid History

Infant : born spontaneously, birth wasassisted by midwife, no history of jaundice,

cyanosis, or seizure.

Childhood : growth and development suitablefor her age.

Adolescence: polite, had a lot of friends, easilymake new friends and outgoing person

Adult : have a lot of friends


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4. Educational Background

Primary School : completed primary school

Secondary school : completed secondaryschool

5. Work history

Patient has no working history

6. Socioeconomical status

Lives with her elder brother in a permanenthouse, good electricity and water resources,with a color TV and motor vehicles.


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1. Family History


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Graphic of illness course

Years

20102012

2006 20112007 2008 20092013


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Summary of Phsyciatric Examination

I. General Appearance

Counciousness : compos mentis

Attitude : cooperative

Motoric : active

Facial expression : good

Verbalization : can talk, clearly and fluently

Physic contact : can be done, appropriate, long enough

Attention : present

Initiative : present


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II. Specific Condition

A. Affective

1.Affective condition : hypertym2. Emotional :

a. Stability : stable

b. Control : controlled c. Echt/unecht : echt

d. Einfulung : inadequate

e. Deep/shallow : shallow

f. Differentiation scale : narrow g. Emotional flow : slow


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B. Intellectual condition of function

a. Memory : enough

b. Concentration : enough

c. Orientation : time orientationgood, special and persons orientation good

d. Knowledge : undetermined

e. Discriminative insight : not disturbed f. Intelligence prediction : average

g. Discriminative judgment : notdisturbed


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C. Sensation and perception abnormalities

1. Illusion : none

2. Hallucination :

Acoustic : none

Visual : none

Olfactory: none

Tactile : none Gustatory: none


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D. Thought process condition

1. Speed of thought process :clear andappropriate

2. Quality of thought process:

a. Clear and sharp :clear and sharp

b. Incoherent : none

c. Sperrung : none d. Hemmung : none

e. Flight of ideas : present

f. Verbigeration : none

g. Preservation : none


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3. Thought condition a. Central pattern : none b. Phobia : none c. Obsession : none d. Delusion : none e. Suspicion : none f. Confabulation : none g. Repulsion : none h. Inferior feeling : none i. Much/little : little

j. Feeling guilty : none k. Hypochondria : none l. Others : none


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E. Instinctual drive and behaviorabnormalities a. Abulia : none

b. Stupor : none c. Raptus/impulsivity : none d. Excitement state : none e. Sexual deviation : none f. Echopraxia : none g. Vagabondage : none h. Pyromania : none i. Mannerism : nonej. Others : none F. Over anxiety : none G. Reality testing ability : no disturbance


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MULTIPLE AXIS RESUME

Axis 1. Clinical syndrome

Patient does not want to take regularmedications, laughs without any reason, shehas delusions of greatness as if she is afamous celebrity. The patient likes shopping.The patients also thinks she has graduatedfrom university and obtained a degree.


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Phyciatric examination

General condition: compos mentis,

cooperative, less initiative, hyperactive,verbalization is clear and sharp,talkative,psychic contact good, appropriate, longenough.


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Specific condition :

1.Affective condition: hyperthym, stable, echt,

2.Intellectual condition of function: memorygood, good concentration, time orientation isgood, knowledge is difficult to evaluate,discriminative insight not disturbed,

intelligence average, discriminative judgmentsnot disturbed.

3.Sensation and perception abnormalities: noillusion ,no hallucination,


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4.Thought process condition: fast, clear andsharp, circumstantial present, delusional,suspicious.

5.Instinctual drive and behavior abnormalities :no disturbance

6.Over anxiety : none

7.Reality testing ability : nodisturbance in behavior, feeling and thinking


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Axis II. Personal disorder and mentalretardation disorder

Personality disorder : none Mental disorder : none

Axis III. General medic condition

No history of head trauma , or malaria whichneeded hospitalization.


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Axis IV. Psychosocial stressor and environment

None

Axis V. Global assessment functional Social: likes shopping and going out at night

Daily Activity: no disturbance.

Leisure/ recreational activity: no disturbance.


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Multiple Axis diagnosis

I . F31.2 Bipolar Affective Disorder, ManicEpisode with psychotic symptoms

II. No Diagnosis III. No Diagnosis

IV. No problems

V .


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Differential diagnosis

F 31.8 Other Bipolar Affective disorders

F 06.31 Organic Bipolar Affective disorder

Therapy

- Chlorpromazine 1 x 1 tablet @ 100 mg

- Risperidone 1 x 2mg


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Prognosis

Clinical : dubia ad bonam

Functional : dubia ad bonam

Social : dubia ad bonam


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Autoanamnesis

Dokter Muda Pasien Interpretation

Sore kak

Perkenalkan nama saya dokter

muda Azrul dan ini teman saya CP

Bisa kami bertanya ke Bulan?

Lagi ngapain tadinya?

Udah makan?

Tau Bulan dimana sekarang?

Udah berapa lama disini?

Kenapa bias sampai disini?

Baa tu?

Sering ngak kedengaran suara

suara, bisikan, Nampak bayangan,

mencium bau?

sekolah sampai kelas berapa

bulan?

Tinggalnya sama siapa bulan?

Sore doc

Nama saya Bulan. Teman kamu

ganteng sekali, hidungnya mancung

Bisa abang

Baru selesai mandi

Makan siang alah, makan malam

alun

Tau, lagi di rumah sakit

Udah hampir 1 bulan

.

Saya sakit jadi dihantar sama

keluarga berobat

Tidak ada bang

.

Saya kuliah ambil S.Pd tapi berhenti

sampai semester 4. Tidak bias

belajar,susah.

Tinggal sama keluarga bang.

Cooperatif

Orientation is not

disturbed

Discriminatifinsignt is good

Discriminatif

judgement is

good

No hallusination

Delusion

Concentration is

good

Bipolar Affective Disorder, Manic Episode With Psychotic

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