BST Dr. Linda, Eta Jonni

7/31/2019 BST Dr. Linda, Eta Jonni

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BIPOLAR AFFECTIVE

DISORDER

Dilla Mareta Amenike (RP. 429)

Rahendra Wijaya Jonni (P.826)

PERCEPTOR :

Dr. Yaslinda Yaunin, SpKJ



CASE PRESENTATION

A 33 years old man was admitted to HB Sa’anin

asylum’s emergency unit on September 11th, 2011 at 11

a.m and escorted by his family. This patient was

permitted to hospitalize by dr. Fadil. Sick for the fifth

time and hospitalized for the fourth time. The sickness is

worse than before.



PATIENT IDENTITY

Name and Age : Dafit Fernandes / 33 years old

MR : 79902

Gender : Male. Place and date of birth : Pariaman, September 23th 1978

Marital status : Single

Address : Pancasila Street No. 30 RT 03 RW 01 Sungai Penuh, Kerinci

Occupation/School : No Occupation/Senior High School

Religion : Islam

Citizen : Indonesian

Tribe : Minangnese



ALLO-ANAMNESIS

Name/Age : Armen Filma/40 years old

Address : Sungai Penuh, Kerinci (0811742897)

Occupation : Trader

Relationship with patient : Older Brother



INTERNAL STATUS

General appearance : Compos Mentis

Vital Sign : Good

Body Shape : astenikus

Height : 180 cm

Weight : 78 kg

Cardiovascular system : No abnormality detected

Digestive system : No abnormality detected

Specific disorder : No abnormality detected



NEUROLOGICAL STATUS

Cranial Nervous (five senses) well

Meningeal Signs : None

High Intracranial Pressure Signs : None Eyes

• Movement : Free to all direction

• Perception : No nystagmus, no diplopia

• Pupil : Round and isokor

• Light Reflex : +/+

• Convergence Reaction : Not examined

• Ophtalmoscopic examination : Not examined



Motoric

Tonus : Eutonus, tremor (+/+ )

Turgor : Good

Strength : Good

Coordination : Good

Reflex : Physiologic (+/+), pathologic (-/-)

Sensibility : No abnormality detected Vegetative Function : Good appetite, sleep well

Basic Function : No abnormality detected

Specific disorder :

Rigidity : None Tremor : +/+

Nasal Stiffness : None

Oculogyric Crisis : None

Torticolis : None

Others : None



LABORATORIUM

( AUGUST, 9 TH 2011)

Hemoglobin : 11 g/dl

Leukocyte : 8300/mm3

Thrombocyte : 210.000/mm3

Diff Count : 0/0/1/83/12/4 Blood Type : A



PRIMARY COUSE OF

HOSPITALIZATION

Patient was restless, almost never slept at night, talked a lot,

inconsequential, irritable, suspicious of others, often threatening,

like chasing other people, hitting a parked vehicle with wooden

beams, destroying household appliances, since 3 months before

hospitalized.

Present complain of patient

There is no complaint at this time.



HISTORY OF ILLNESS 1999 (around October)

Patient were studied at the University of Eka Sakti. GPA of patient is always low and

tends to decrease. 1st semester , GPA was 2.2, 2nd semester , GPA was 1.5, 3rd

semester, GPA was 1.5, and 4th semester, GPA was 1. Patient began to blame thelecturer for the value obtained. Patient felt that he is always correct in answering the

exam questions and tasks. After that the patient began to forget things. Forgot to

create a task, forgot to close the rice and side dishes, forgot to turn off the lights,

stoves, and others. Patient using marijuana in the year, also ever use a syringe, so

patient drop out. Patient become lazy, likes silence, muse, and often looked sad. Until

one day, the patient ran home leaving his nephew for a walk on the grounds chasing

bad guys. When in fact there is no person who intends evil to him. Then the patient

was taken to Puti Bungsu asylum for treatment, and was given outpatient treatment.



2000 (beginning of the year)

After several months of treatment, no installment, the patient was brought back to

the Puti Bungsu Hospital. Patient treated at Puti Bungsu asylum for about 23 days.

Patient went home in a state of calm and on a regular basis. The patient always

controlled his present condition after discharge.

2007 (forgot month)

Patient was restless, angry, always suspicious of other people, hitting a parked vehicle

with wood beams, and lots of talking. Previously, patient was not taking medication

regularly since last year. The patient was taken to Puti Bungsu and treated for about

25 days. Patient went home in a state of calm and on a regular basis. The patient

always controlled his present condition after discharge.



2010 (October)

Patient often visited the house of relatives, neighbours andfriends, because that is still in an atmosphere of Eid. Each visit,

patient always asked for were treated with coffee. Until that day,

he drank up to 8 cups of coffee at the shop. Suddenly, throwing

his coffee cup on the floor. From then on, he complained that he

could not sleep. Patient was restless, loquacious, inconsequential,

alternation, always felt everything the world mean for him, felt asif by magic, and complained about short sircuit sound. The

patient was taken to the HB Saanin asylum and hospitalized there

about 1.5 months. Patient went home in a state of calm and on aregular basis. The patient always controlled his present conditionafter discharge.



2011 (September)

Since early 2011, the patient did not want to take medication because

they feel healthy. The patient began to show abnormalities in June. The

patient was restless, almost never slept at night, talked a lot,

inconsequential, irritable, suspicious of others, often threatening, like

chasing other people, hitting a parked vehicle with wooden beams,

destroying household appliances, felt as if by magic, and complained

about short sircuit sound. The patient refused to hospital. Finally

Patient’s family deceived him and took the patient to a HB Saanin

asylum for treatment.



PREMORBID HISTORY

Infant : born spontaneously, birth was assisted by

midwife, no history of jaundice, cyanosis, and

seizure.

Childhood : growth and development according to his age

Adolescence : had a lot of friends, easy making new friends

and outgoing person



EDUCATIONAL BACKGROUND

Elementary School at SD N 27 Sungai Penuh,

graduated in 6 years top ten Junior High School at SMP N 8 Sungai Penuh,

graduated in 3 years top ten

Senior High School at SMA N 1 Sungai Penuh,graduated in 3 years, achievement decreased



SOCIAL ECONOMY HISTORY

Living with his parents, had a permanent house, had a

TV and electricity on it, water supply from Municipal Water Corporation, had no home-phone, had a

motorcycle. His parents and him have no occupation.

He got money from his older brother. Usually, Rp.20.000/day, and he feels enough.



BIOLOGICAL DEVELOPMENT

BACKGROUND

Head trauma’s history was present, but not vomiting

and was never hospitalized after trauma

No history of malaria, typhoid, or brain and

neurological disease

Marijuana abuse and alcoholic history



FAMILY HISTORY

♂ ♀ ♂ ♀

♂ ♀ ♀ ♂ ♂ ♂ ♀ ♂

♀ ♀ ♂ ♀ ♀ ♀ ♂ ♂

There were no family members that has same symptoms likethis.



CONCLUSION OF PSYCHIATRIC

EXAMINATION

General appearance

Consciousness/sensorial : compos mentis/good

Attitude : cooperativeMotoric : active

Facial expression : rich

Verbalization : speak clearly

Physic contact : could be done / inappropriate / long enough

Attention : good

Initiative : good



AFFECTIVE

Affective condition : hypertim

Emotional :

Stability : stableControl : good enough

Echt/unecht : echt

Einfuhlung : inadequat

Deep/shallow : shallow

Differentiation scale : narrow

Emotional flow : fast



INTELLECTUAL CONDITION OF

FUNCTIONMemory : good

Concentration : not good enough

Orientation : good

General and schooling knowledge : can not predicted

Discriminative insight : disturbed

Intelligence prediction : averageDiscriminative judgment : disturbed

Intelectual deterioration : none



SENSATION AND PERCEPTION

ABNORMALITIES

Illusion : none

Hallucination :

Acoustic : present, since 3 month ago decrease in last 7 days(hearing short sircuit sound)

Visual : none

Olfactory : present, since 3 month ago decrease in last 7 days

(scorch odor)

Tactile : none

Gustatory : none



THOUGHT PROCESS CONDITION

Sperrung : none

Hemmung : none

Flight of ideas : none

Verbigeration : none Preservation : none

Speed of thought processs : fast

Quality of thought process:

Clear and sharp : clear and sharp enough Circumstantial : none

Incoherent : none



THOUGHT CONDITION

Central pattern : present

Phobia : none

Obsession : noneDelusion : present

Suspicion : none

Confabulation : none

Repulsion : none Inferior feeling : none

Much/little : much

Feeling guilty : none

Hypochondria : none

Others : none



INSTINCTUAL DRIVE AND

BEHAVIOR ABNORMALITIES

Abulia : none

Stupor : none

Raptus/impulsivity : none

Excitement state : present, since 3 month

ago, decrease in the last 1 and half months

Sexual deviation : none

Echopraxia : none

Vagabondage : none

Pyromania : none

Mannerism : none

Others : none

Over anxiety : none

Reality testing ability : disturb in

behavior, feeling and thinking



MULTIPLE AXIS RESUME

Axis I. Clinical Syndrome

Patient was restless, almost never slept at night, talked a

lot, inconsequential, irritable, suspicious of others, oftenthreatening, like chasing other people, hitting a parked

vehicle with wooden beams, destroying householdappliances, lack of sleep and adequate diet since 3 monthsbefore hospitalized. Sick for the fifth time andhospitalized for the fourth time. The sickness is worsethan before.



Phsyciatric examination:

General Appeareance: compos mentis, cooperative, active, rich, can speak clearly, psychic contactcould be done, inappropriate and long enough.

Specific condition:

Affective condition: hypertim, stable, good enough, echt, inadequate, shallow, narrow, fast.

Intellectual condition and function: good memory, concentration is not good enough, good

orientation, absent intelectual deterioration, discriminative insight and judgment are disturbed. Sensation and perception abnormalities: no illusion, acoustic and olfactoric hallucination present since

3 month ago, decrease in last 7 days.

Thought process condition: fast, clear and sharp enough, central pattern present, delusion present,

much.

Instinctual drive and behavior abnormalities: excitement state is present, since 3 months ago, decrease

in the last one and half months

Overt anxiety: none

Reality testing ability, disturbed: behavior, feeling and thinking



Axis II : Personality Disorder and Mental RetardationDisorders

Personality: outgoing, has a lot of friend

Mental retardation: none

Axis III : General Medical Condition

Head trauma’s history was present

No history of malaria, typhoid, or brain and neurological

diseaseMarijuana abuse and alcoholic history



Axis IV : Phsychosocial Stressor and EnvironmentDrug withdrawal

Axis V: Global Assessment of Function

Social relationship couldn’t be done since sick Spending time with watching TV, travelling, couldn’t be

done since sick



MULTIPLE AXIS DIAGNOSIS

F.31.2 Bipolar Affective Disorder Manic Episode with

Psychotic Symptoms No Diagnosis.

Marijuana abuse and alcoholic history

Drug Withdrawal

GAF 41-50.



DIFFERENTIAL DIAGNOSIS

F 31.6 Bipolar Affective Disorder Mixed Episode

F 25.0 Manic type schizoaffective



THERAPY

Risperidon 2 x 1 mg

Haloperidol 2 x 5 mg

THP 2 x 2 mg

Education to the family



PROGNOSIS

Clinical : dubia at malam

Functional : dubia at malam

Social : dubia at malam



THANK YOU

BST Dr. Linda, Eta Jonni

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