Case Report Session

BIPOLAR AFFECTIVE DISORDER CURRENT EPISODE

HYPOMANIC

BY :

DION PRATAMA P.1476

RAHMAT NURUL YUDA PUTRA P.1670

PRECEPTOR:

Dr. YASLINDA YAUNIN SP. KJ

PSYCHIATRY DIVISION

MEDICAL FACULTY OF ANDALAS UNIVERSITY

RSUP DR M DJAMIL PADANG

2015
 PSYCHIATRIC PATIENTS STATUS

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.

Patients 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

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

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Neurological Status

GCS 15, pupil reflex positive, corneal reflex positive

Cranial nerves : Vision, smelling, taste, hearing, tasting and tactile

are all normal

Meningeal Signs : No signs present

Increased Intercranial Pressure : Projectile vomiting (-), Progressive headache (-)

Eyes

- Movement : Free to move in all directions

- Perception : No nystagmus, no diplopia

- Pupil : Round and isochoric

- Light Reflex : +/+

- Convergence : Not examined

- Opthalmoscopy : Not examined

Motoric : Eutonus, Eutrophic, no tremor

Muscle strength superior extremity 555/555,

inferior extremity 555/555

Sensibility : No disorder found

Specific disorder : No disorder found

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Autoanamnesis (8th of September 2015)

Pertanyaan Jawaban Interpretasi

Pagi, da. Kenalkan, kami Buliah Compos mentis kooperatif

dokter muda yuda jo wira.

Buliah wak maota da?

Sia namo uda? Refi

Lengkapnyo sia da? Refi Adi

Bara umua uda? 23 tahun Orientasi waktu baik

Uda tingga dima? Di sungai sapiah, kuranji Orientasi tempat baik

Manga uda kamari? Ka Awak ka kontrol.

barubek? Kontrolnyo sakali tiok Discriminative insight baik

bulan.

Sabalum kontrol baa Kato dokter disiko awak

keadaan uda? ado depresi.

Depresi baa? Iyo awak tu dulu acok

sadiah pak, pas sakolah

acok digalakan bencong.

Di rumah awak digalak an

badut.

Sadiah uda ko baa? Yo awak maibo gitu,

kadang sampai manangih,

kok bisa awak digalakan.

Baa kok badan wak ko

lamah waktu ketek

Tu pernah maraso hal yang Iyo, kadang wak mudah

lain ndak, selain sadiah- emosi, tu berang-berang se

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sadiah? ka urang, tahun 2007 tu kan

dek itu mah, mungkin dek

lah panuah. Lah lamo bana

saba

Lah bara lamo mode iko Alah lamo, sejak SD,

da? Barubah-ubah emosi kadang biaso se ndk ado

tu? tapikia apo-apo, tapi

kadang sadiah, tu tibo lo

berang-berang baliak.

Tingga jo sia se di rumah Jo amak wak, tu kakak wak

da? baduo

Baa ndak ado ayah di Awak broken home, ayah

rumah? wak lah carai

Bilo ayah carai? Waktu wak ketek, kelas 3

SD

Baa kok bisa carai? Kato ayah, kan anak lah

gadang sadonyo, ndak baa

di tinggaan, tu nyo dapek

yang labiah mudo

Ado saudara yang sadiah Ado, kakak cewek, nomor

mode iko? 3

Pernah mandanga suaro Ooo, halusinasi, ndak ado

yang cuma uda yang bisa wak doh

danga? Halusinasi (-)

Mancaliak urang yang ndak Ndak ado jo

nampak dek urang lain?

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Uda pernah meraso paling Hebat lah dokter pado wak Waham (-)

pintar, hebat? lai, awak tamat SMK nyo

Lah pernah dirawat? Indak

MEDICAL RECORD (AUTOANAMNESIS)

1. Main reason of Medical Check-up

Medical control for every month

2. 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.

3. History of Medical Condition

Year 2001 : Parental Divorce, when the patient was 9 Years old, patient feels

sadness and sorrow, his dad hadnt take the responsibility to

take care of him and his family. After that, patient often

pondering and pull himself from society

Year 2007 : Patient feels more irritable and angry to his friends for mocking

him. He chased them and took ceramic as a weapon. Patient

says that he lost his temper because they mock and hurt him for

a long time. They were taken to Counseling Teacher, and the

teacher gave him advice to meet a doctor. He came to

Psychiatric Policlinic and received some drugs as medication,

and doctor ordered him to control his medication for every

month

Year 2011 : He was stressed out because the Senior High School National

Exam was near. He started to think about his future, still

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 mocked by his friends and neighborhood, thinking what he

going to do, and his partner for life. And several month after

that, he felt more irritable again and angry with his

neighborhood because they was singing loudly outside his

house in his bed time.

4. 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

5. Educational Background

Educated till third year of senior high school.

6. Work history

Working as a goat milker and earned Rp 400.000 per month

7. Marital status

Patient is single

8. 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.

9. Family History

One of patients sister has the same symptoms as him

(patient)

Graphic of illness course

Disturbed by
Bullying Neighborhood
victim
Parental
Divorce
Exam

2001 2007 2011 2015

Summary of Phsyciatric Examination

I. 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

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II. Specific Condition

A. Affective

1. Affective condition : hipertym

2. Emotional :

a. Stability : stable

b. Control : controlled

c. Echt/unecht : echt

d. Einfuhlung : adequate

e. Deep/shallow : deep

f. Differentiation scale : wide

g. Emotional flow : fast

B. Intellectual condition of function

a. Memory : good

b. Concentration : good

c. Orientation : time, place, situation, and person

orientation is not disturbed

d. Knowledge : normal-average

e. Discriminative insight : not disturbed

f. Intelligence prediction : normal-average

g. Discriminative judgment : not disturbed

C. Sensation and perception abnormalities

1. Illusion : none

2. Hallucination :

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 Acoustic : none

Visual : none

Olfactory : none

Tactile : none

Gustatory : none

D. Thought process condition

1. Speed of thought process : fast

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 : none

f. Verbigeration : none

g. Preservation : none

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 : exist

i. Much/little : much

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 j. Feeling guilty : none

k. Hypochondria : none

l. Others : none

E. Instinctual drive and behavior abnormalities

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 : none

j. Others : none

F. Overt anxiety : none

G. 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

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FORMULATION OF DIAGNOSE

Based on anamneses, the history of medical disorder and the examination, in this

patient we found some changes of behavior pattern and affect that clinically significant

and disability in social function. Therefore, based on PPDGJ III, we conclude that this

patient have a psychology disorder.

In anamneses of history of medical illness, patient never had any injury in head,

and other disease that physiologically can make psychology disorder. So, in this case,

Organic mental disorder can be excluded (F.00-09).

In this patient, we found no history of drug abuse, so the behavior and mental

disorder caused by psychoactive agent can be excluded (F.10-19)

In this patient, we found behavior and affect disorder, we found some episode of

depression followed by manic episode. Those episodes happened for several days.

Based on PPDGJ III we can conclude this disorder as Bipolar Affective Disorder,

current episode hypomanic (F31.0).

From patient personality history, He didnt have any personality disorder. There

is no mental retardation, so there was no diagnose for AXIS II. This patient also didnt

have any general medical condition that significant for his condition, so there is no

diagnose for AXIS III.

Patient have some problem with his social environment, he was a victim of

bullying and parental divorce, so he likes to be alone. We can conclude, there was a

problem with his primary support group and his social environment for AXIS IV.

In AXIS V, 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. So, for

Global Assesment of Functional scale was scored 80-71

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MULTIPLE AXIS RESUME

Axis 1.

Clinical syndrome

Patient have unstable mood began at 2001, became angrier to his friends at

2007, he chased them and insult them with ceramic as weapon. 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 :

1. Affective condition : hipertym, stable, echt, deep, wide, fast

2. 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.

3. Sensation and perception abnormalities : no illusion, no hallusinasion (auditory,

visual, olfactory, and tactile).

4. Thought process condition : clearly and sharp, coherent

5. Instinctual drive and behavior abnormalities : none

6. Over anxiety : none

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 7. 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. None

Axis IV. Problem with primary support group

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

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Therapy

- Olanzapine 4 mg

- Thiamin 2 mg

- Piridoxine 2 mg

Mf pulv dtd No. XXX

S1dd caps I

Psychotherapy

For Patient

Supportive psychotherapy

We give him a soothe advice, empathy, help the patient to identify his problem,

and become his window to calm his mood.

Psychoeducation

For Family

Psychoeducation about patient disorder

Prognosis

Clinical : bonam

Functional : bonam

Social : dubia at bonam

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 CASE ANALYSIST

Patient was diagnosed with Bipolar Affective Disorder, current episode hypomanic

(F31.0). Bipolar Affective Disorder was a recurrent episodes of affective disorder,

which at certain times there was an increased affect and at other times a decreased

affect. Hypomania refers to a distinct period of at least a few days of mild elevation of

mood, sharpened and positive thinking, and increased energy and activity levels,

typically without the impairment characteristic of manic episodes. Symptom that occurs

is :

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep.

3. More talkative than usual or pressure to keep talking.

4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant

external stimuli), as reported or observed.

6. Increase in goal-directed activity (either socially, at work or school, or sexually)

or psychomotor agitation.

7. Excessive involvement in activities that have a high potential for painful

consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions,

or foolish business investments).

Based on literature and symptoms, the patient diagnose was found from patient

medical history and present condition. There was repeated changes of affect or mood

from 2001 until now. Patient was talking too much, hipertym, echt, and fast emotional

flow. His thoughts are racing, mainly about his job, future, and relationship goals. From

auto-anamneses, there was no decreased need for sleep, and no disturbance in his

activity. The differential diagnoses for this patient is Bipolar Affective Disorder, current

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episode manic, without psychotic symptoms (F 31.1) and Bipolar Affective Disorder,

current episode mixed (F 31.6). 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. The main treatment for this patient is Olanzapine. Olanzapine is an atypical

anti-psychotic that mainly used for Bipolar disorders, especially for mania condition.

Olanzapine have a few side effect and its common side effect is weight gain.

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