Bed Side Teaching

BIPOLAR AFFECTIVE DISORDER MANIC TYPE WITH PSYCHOTIC SYMPTOMS

BY: ALFA FEBRIANDA PRATIWI DIAN PRAMANA P.1271 P.1273

PRECEPTOR Dr. Yasli !a Ya" i # S$.%&

PSYCHIATRY DEPARTEMENT MEDICAL FAC'LTY ANDALAS 'NIVERSITY RS& H.B. Saa i PADAN( 2)13

CASE REPORT A female patient, 44 years old, was admitted to Emergency Unit of RSJ H.B. Saanin Padang on o!em"er #t$, %&1' at %%(&& pm. S$e came to HB Saanin Hospital "y $er family "eca)se s$e $it t$e old man wit$ a sig$, t$rowing stones passer, angry for no o"!io)s reason, "rea* glass $o)se, felt to "e t$e most powerf)l. Pa*i+ * i!+ *i*, : ame Se, +R Born date / age +arital Stat)s 1cc)pation/Ed)cation Address Religion ationality Race INTERNE STAT'S 2eneral Stat)s Body s$ape Blood Press)re Heart Rate Respiration Rate 6emperat)re Heig$t 8eig$t ( 5+5 ( astenic ( 1%&/.& mmHg ( strong palpa"le, reg)lar, .0 ,/min)tes ( toracoa"dominal, reg)lar, %& ,/min)tes ( '0,0 o5 ( 17. cm ( 9& *g ( in normal range ( in normal range % ( +rs. R ( -emale ( &1%4.4 ( +ay 1st, 1#0./ 44 years old ( +arried ( -armer/ 2rade 0 elementary sc$ool grad)ation ( 3along *amp)ng rim"o, an sa"aris, Padang Pariaman ( 4slam ( 4ndonesia ( +inang*a"a)

5ardio!asc)lar System Respiratory Sytem

Spesific System NE'ROLO(IC STAT'S 4. Scalp ne)ro :senses; +eningeal sign 4ntracranial Press)re sign Eyes( = = = = = = =

( in normal range

( in normal range ( 3ernig<s sign :=; ( progressi!e $eadac$e :=;, pro>ectil !omit :=; ( free, istagm)s :=; ( ?iplopia :=;, !is)s not c$ec*ed ( circle/isoc$ors ( :@; ( @/@ ( not c$ec*ed ( not c$ec*ed

mo!ement :paresys, nistagm)s, etc.; perseption :?iplopia, !is)s, etc; p)pil, form con!ergent reaction lig$t reaction cornea reaction 1pt$almologic test :f)nd)s,etc;

44. +otoric = = = = = ton)s (e)ton)s t)rgor ( normal power ( 777 777 coordination ( good P$ysiologic refle, :patella; ( @/@, patologic refle,:"a"ins*y;( =/= ( $ard and smoot$ are good ( eno)g$ meal, eno)g$ sleep ( reading, writting, drawing, acti!ities and lang)age can "e done well A4. Spesific disorder ( Rigid 6remor asal stiffness ' ( none ( none ( none 777 777

444. Sensi"ilities 4A. Aegetatif f)nction A. Basic f)nction

1cc)loloiri* crisis 6orti*olis 1t$ers ALLOANAMNESIS ame / age Se, Address/p$one 1cc)pation Ed)cation Relations$ip
I.

( none ( none ( none

( Bad)ng 2asli 5$an/ '0 years old ( +ale ( Bing*)ng, Padang Pariaman/ &.1%0941'&70 ( Entreprene)r ( Senior Hig$ Sc$ool ( ep$ew

6$e main reason treatment S$e $it t$e old man wit$ a sig$, t$rowing stones passer, angry for no o"!io)s reason, "rea* glass $o)se, felt to "e t$e most powerf)l.

II.

6$e main complaint of patients at t$is time( no complaints 5)rric)l)m co)rse of t$e disease = %&&4 Agitated patients, patients li*e t$rowing appliance, $it t$e elderly, $o)se "rea*ing t$ings, li*e t$e way o)t of t$e $o)se wit$o)t t$e direction of t$e goal alone. A lot of tal* and la)g$ter itself, sleeping less. Pre!io)s patient angry, fig$ting wit$ t$e neig$"or ne,t to $er $o)se. 6$e patient was ta*en to t$e $ospital HB Saanin families and patients were treated for 17 days, t$e patientCs $ome r)n. 5ontrol patients ")t ne!er ate medicine. = 1cto"er %&1' Agitated patients in t$e first mont$, patients li*e t$rowing stones at passers="y, $it t$e elderly, "ro*e t$e glass $o)se, li*es t$e way o)t of t$e $o)se wit$o)t p)rpose and direction sometimes did not come $ome. A lot of tal* and la)g$ter itself, li*e ")rn, sleep less, and most people feel so strong. Pre!io)s patient angry wit$ t$e person w$o ta*es care of gat$ering rice patient, t$e patient is ta*ing wit$ $im

III.

some. Patients did not recei!e t$e money ta*en away. -inally on # = %&1' pasein ta*en to t$e $ospital emergency room HB Saanin. 4A. Premor"id $istory

o!em"er

= Ba"y( Birt$ spontaneo)s, >)st mont$s, $elped "y a s$aman, ")rst into tears, no seiD)res, no "l)e, no yellow. = 5$ildren( 2rowt$ and de!elopment of t$e appropriate age c$ildren = 6eens( 6$e growt$ and de!elopments according teenagers $is age, o"edient to t$eir parents. = Ad)lt( +any friends, li*e to $ang o)t, $a!e started to loo* sic*
V.

History of ed)cation = S? 7& 3oto, Paya*)m")$, primary sc$ool grade 0 History of weddings +arried

VI.

A44. Employment $istory -armers

VIII. Socio=economic $istory

Bi!ed wit$ $er $)s"and and 4 c$ildren, semipermanent $ome, t$ere is a 6A, no electricity, tap water, do not $a!e a motor !e$icle.
IX.

-amily $istory of disease .

. -

- .

. -

5oncl)sion( 6$ere is no family of patients s)ffering from mental disorders. .

X.

5$art t$e co)rse of disease E)arrel wit$ neig$"ors +oney ta*en away, F)arreling wit$ neig$"ors, $)s"ands >o" loss, dr)g wit$drawal

%&&4 A"*/a a0 +sis P+r*a ,aa &a1a2a Asalam)alai*)m *enal*an ") 8aalai*)msalam saya do*ter m)da Alfa. 3ami ma) 6iwi dan Bole$ ngo"rol ini teman saya do*ter m)da se"entar, "ole$ ")G ama i") siapa ")G Berapa )m)r i") se*arangG 4") ingat tanggal la$ir i")G 4") ta$) se*arang "erapa ")G 6anggal "erapa i") ta$)G disini ")G 4") ta) dimana ini se*arangG % ?esem"er S)da$ "erapa $ari i") dirawat S)da$ 19 $ari. ama i") Ra$maini 47 ta$)n 1 mei 1#0.

1*to"er %&1'

I *+r$r+*asi %+sa!ara 2ai3 %//$+ra*i4

Da,a i 5a* 2ai3

ta$)n 6a$)n %&1'.

Ori+ *asi 1a3*" 2ai3

6a$), ini di R)ma$ Sa*it >iwa Ori+ *asi *+0$a* 2ai3 2ad)t Padang.

Siapa yang "awa i") *esini G *esiniG

Ana* *a*a* i"). *esini.

Ori+ *asi $+rs/ al 2ai3 i si58* *+r5a 55"

4") ta$) mengapa i") di"awa 2a ta) i") *enapa i") di"awa Dis6ri0i a*i7+ 8a*t) di "awa *esini *ata 2a da, mala$ i") "ercanda 0

*el)arga i") mara$=mara$G

dalam s$ooting

mo"il. di

3atanya tapi

+edan,

di"awa *e sini. 3enapa s$ooting di +edan E$ i") "er"icara l)pa. 4ya ")G *e"et)lan "icara nga)r. ?)l) i") s)da$ perna$ di"awa *e sini ta$)n %&&'. 3enapa i") di"awa *esini 2a ta) i"), *atanya i") mara$= %+5a!"8a "0"0 a!a. wa*t) it) ")G mara$. 8a*t) di di"awa *e sini d)l) i") disi*sa, dip)*)l, ditin>) dari "ela*ang sama orang. 1rangnya "er*)mis tipis, dia mara$=mara$ i") >)ga, *atanya mamp)sla$ *a) matila$ *a). +emang "enar orang ata) 1rang, "er*)mis tipis dia. c)ma "ayangan ")G Se"el)m di "awa *esini i") 4") *er>a disawa$, ng)r)s *er>anya apa ")G i") "ilang apa lagi *e i")G padi. >)lo=>)lo, arisan, se*ali pasang 1&& padi, i") s)da$ 1% *ali pasang, tapi yang *e 1' di"awa )ang i"), >adi i") ga terima, $ar)snya i") dapat )ang se>)ta empat rat)s, se*arang )da$ ga ses)ai lagi, ""m )da$ nai*, ga c)*)p. Jadi i") ga terima. Siapa yang "awa *a")r )ang 2a ta) t)*angnya t) lari, i") 9 8a*t) di "awa *esini *el)arga 2a, awalnya, saya memasang

i")G

cari ana*nya, *atanya s)da$ lari *e Ja*arta, i") co"a telpon dia ter)s tapi ga dapat, *atanya s)da$ lari *e S)lawesi.

3atanya di r)ma$ i") mara$= 2a i") 5)ma mara$ sama mara$, lempar "at) *e tetangga. 2a, tetangga i") r)ma$ i") di")ang Wa8a0 6"ri5a tempat orang,iyaG +emang *enapa tetangga i")G sem)a sampa$ r)ma$, seola$ penamp)ngan *otoran, seperti +alaysia 4ndonesia, apa yang saya tanam dia "ong*ar. 4") ada li$at dia "ong*arG 4ya, dia yang paling de*at, saya perna$ li$at dia ")ang, saya tanam >ag)ng disiramnya pa*ai minya* tana$, gimana caranya 4") merasa dia omongin i")G 4") "erantem sama diaG ma) t)m")$, dia ")s)* $ati. 3enyataan, i") li$at langs)ng. 2a, mara$ a>a, i") caci ter)s lari dia. ?ia ga "erani. 5)ma dia tetangga i"), *ami tinggal di rim"a. 4") perna$ meli$at ses)at) Ada, wa*t) se"el)m tid)r, Hal"si asi 7is"al a!a yang ane$ ga, *aya* setiap malam, i") li$at sapi, lem") "anya* warna pin*. ?alam mimpi >)ga ada. 4") perna$ dengar seperti ada 2a ada. orang "er"isi* ga sama i")G Rasa=rasa dipegang ada ")G 2a ada. . Hal"si asi *a3*il *i!a3 a!a Hal"si asi a3"s*i3 *i!a3 a!a "ayangan="ayangan gt)G

Ada menci)m "a)="a)an yang Ada, "a) ma*anan tapi ga ada Hal"si asi /l4a3*/ri a!a ane$ ga* ")G ma*anannya.

4") merasa i") le"i$ $e"at 2a ada. ata) *)at ga dari orang lainG 4") merasa pi*iran i") 4ya, rasanya pi*iran i") di T8/"58* 1i*8!ra1al a!a dengar sama orang. *aya* gt). P+rasaa i 4+ri/r *i!a3 a!a Hi$/38/ !ria *i!a3 a!a

didengar sama orang lainG mem"aca pi*iran orang lainG

3ala) men)r)t i"), i") "isa S)sa$, orang pintar a>a "isa

4") perna$ merasa renda$ diri 2a* ada. dari orang lainG 3ala) sa*it=sa*it di )l) $atiG 2a* ada.

4") ada ta*)t sama ses)at) 2a* ada ga*G Ata) merasa cemasG S)ami i") *er>a apa ")G Sama "apa* gimana ")G 6)*ang "eca*. A*)r a>a, awalnya d)l) *ami di>odo$*an sama orang t)a. Jadi se*arang i") saying sama Saya l)pa r)pa s)ami saya, dia s)ami i")G dipecat, *er>anya ga "ec)s, "apa* >at)$ sa*it p)la*, dia sa*it ?+, dia"etes.

F/2ia *i!a3 a!a

4") merasa i") sa*it ")G 2a, ga wa>ar, i") 5)ma ma) Dis6ri0i a*i7+ 8a>ar ga i") di rawat di siniG menga>ar tetangga i"),masa *+r5a 55" dari *ecil sampai se*atang ma) digit)in sama dia. 4") ta) per"edaan "ola sama Bola isi gas *osong, >er)* Dis6ri0i a*i7+ >er)*G *enyataan ada rasa manis 2ai3 #

i si58*

9"!5+0+ *

asam. 3el)ar dari sini i") ma) 4") ma) >)alan "a*so sama es. A2"lia *i!a3 a!a ngapain ")G ")G Se"el)mnya i") >)al sate. "ersala$, saya yang ditip). 4") ada merasa "ersala$ tida* 2a, *enapa saya $ar)s rasa

Bai*la$ "), sampai sini a>a Ha ga papa, sama=sama na*. *ita ngo"rol d)l) ya "), terima *asi$ "). RES'ME AND CONCL'TION OF PSYCHIATRIC E:AMINATION I. (+ +ral S*a*"s a. 5oncio)ness / sensori)m ". Be$a!ior c. +otoric "e$a!ior d. -acial E,pression f. Psyc$ic contact II. S$+si4i6 C/ !i*i/ A. A44+6* S*a*+ 1. %. a. Sta"ility ". 5ontrol c. Ec$t=)nec$t d. Einf)$l)ng e. ?ept$/s$allow g. Emotion flow Affecti!e Emotion life ( )nsta"le ( eno)g$ ( ec$t ( inadeF)ate ( s$allow ( fast ( $ipertim ( compos mentis/good ( cooperati!e ( acti!e ( ric$ ( can spea* well, clearly, long time ( co)ld "e done, fair eno)g$, long time Attention 4nisiati!e ( good ( present

e. Aer"alisation andlang)age competence

f. ?ifferential scale ( narrow

B. I *+ll+6*"al C/ !i*i/ a ! F" 6*i/ 1&

a. Recall +emory ". 5onsentration c. 1rientation d. 3nowledge and sc$ool relation e. ?iscriminati!e insig$t f. 4ntelligence prediction g. ?iscriminati!e >)dgement $. 4ntellect)al deterioration C. S+ sa*i/ a !$+rs+$*i/ a2 /r0ali*, a. 4ll)tion = Aco)stic = Ais)al = 1lfactory = 6actile = 2)statoric ( none ( none ( present ( present ( none ( none ". Hall)cinations (

( good ( dist)r"ed ( good ( $ard to meas)red ( dist)r"ed ( a!erage ( good ( none

D. T8/"58* $r/6+ss 6/ !i*i/ 1. Speed of t$o)g$t processs %. E)ality of t$o)g$t process a. 5learands$arp ". 5irc)mstantiality c. 4nco$erent d. Stagnant e. Bloc*ing f. -lig$t of ideas g. Aer"igerationperse!arati!e '. 6$o)g$t 5ontents a. 5entral pattern ( none 11 ( none ( none ( clear eno)g$ and s$arp eno)g$ ( none ( none ( none ( none ( fast

". P$o"ia c. 1"session d. ?el)tion e. S)spicio)s f. 5onfa")lation g. Rep)lsion $. 4nferior feeling i. +)c$/little >. -eeling g)ilty *. Hypocondria l. 1t$ers

( none ( none ( present ( present ( none ( present ( none ( m)c$ ( none ( none ( none

E. I s*i 6*"al Dri7+ a ! B+8a7i/r A2 /r0ali*i+s a. A")lia ". St)por c. Rapt)s / imp)lsi!ity d. E,citement state e. Se,)al de!iation f. Ec$opra,ia g. Aaga"ondage $. Piromani i. +annerisme >. 1t$ers F. O7+r* A ;i+*, none (. R+ali*, T+s*i 5 A2ili*, ?ist)r" in "e$a!ior, feeling and t$in*ing M'LTIPLE A:ISRES'ME 1% ( none ( none ( none ( none ( none ( none ( present ( none ( none ( none

A;is I. Cli i6all, S, !r/0+ Patient $it parent wit$ a sig$, angry for no o"!io)s reason, felt to "e t$e most powerf)l. 2eneral Stat)s ( composmentis, ric$ attention, can spea* well clearly, psyc$ic contact can "e done, long time. Spesific sign( A. A44+6* S*a*+( $ypertim, )nsta"le, ect$, inadeF)ate, s$allow, narrow and fast. B. I *+ll+6*"al C/ !i*i/ a ! F" 6*i/ ( less memory and impaired concentration, a good time orientation, discriminati!e insig$t dist)r"ed. ?iscriminati!e >)dgment normal. 5. S+ sa*i/ a ! $+rs+$*i/ a2 /r0ali*,( no ill)sions, $all)cinations present :!is)al and olfactory; ?. T8/"58* $r/6+ss 6/ !i*i/ ( fast, clear eno)g$ and s$arp eno)g$. E. I s*i 6*"al Dri7+ a ! B+8a7i/ral A2 /r0ali*i+s( !aga"ondage are present. -. O7+r* A ;i+*,( none 2. R+ali*, T+s*i 5 A2ili*,( dist)r" in "e$a!ior, feeling and t$in*ing.

A;is II.P+rs/ ali*, Dis/r!+r!a M+ *al R+*ar!a*i/

=

Personality ( no personality disorder +ental Retardation( none.

A;is III.(+ +ral M+!i6al C/ !i*i/ 6$ere<s no $istory of malaria, typ$oid, capitis tra)ma, and ot$er disease t$at need to "e $ospitaliDed. A3sis IV. Ps,6/s/6ial S*r+ss/r a ! E 7ir/ 0+ *
= fig$ts wit$ neig$"ors = c$eated and money gat$ering patient was ta*en "y t$e "oard = t$e $)s"and loses a >o" = t$e patient does not want to ta*e medication

A;is V. (l/2al Ass+s0+ * /4 F" 6*i/ 1'

= social relations$ips :!isiting friends, attending in!itations; can not "e performed since t$e

$ospital
= spend leis)re time :leis)re, watc$ing, roads; can not "e performed since t$e $ospital

M'LTIPLE A:IS DIA(NOSIS 4. 44. 444. 4A. A. -.'1.% Bipolar Affecti!e ?isorder +anic 6ype 8it$ Psyc$otic Symptoms o diagnosis o diagnosis Economics and social pro"lems 2A- 41=7& -.%7.& S*iDoaffecti!e +anic 6ype -.'&.% +ania wit$ Psyc$otic Symptoms

DIA(NOSIS DIFFERENSIAL

THERAPY R+6/00+ !+! T8+ra$, Psyc$ot$erapy = -amily t$erapy PRO(NOSIS E)o ad !itam (d)"ia et "onam E)o ad sanam (d)"ia et "onam E)o ad f)ngsional (d)"ia et "onam 5PI 1, 1&& mg 6HP ',% mg Haloperidol ',1,7 mg Aitamin B 3omple*s ',1 ta" Aitamin 5 ',1 ta"

14