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“PUYA”
A case report on
Bipolar Disorder Type I with Psychotic Features
Submitted by:
Submitted on:
August 15, 2018
Submitted to:
VSMMC Department of Psychiatry
Resident In-Charge:
Euriz A. Calmerin, MD
TABLE OF CONTENTS
ACKNOWLEDGEMENT
OBJECTIVES
General Objective:
To discuss the case of patient EM, a 27 year old, female, married, Jehovah’s Witness, housewife
residing at Ticad, Bantayan Island, Cebu.
Specific Objectives:
I. General Data
Informant and Reliability: Patient, Sister
Patient EM, a 27 year old, female, married, Jehovah’s Witness, housewife residing at Ticad, Bantayan
Island, Cebu came in for the first time at VSMMC CBS last August 7, 2018.
Chief Complaint:
“Ambot ngano naa ko diri. Gipa-anhi rako nila para mu kalma” as verbalized by the patient. “Sige man
gud ni siya manghasi sa balay, dapatan ug sumbag-sumbagon niya iyang bana. Dili pud siya matulog” as
verbalized by the patient’s sister.
One year prior to consult, patient was noted to isolate herself from the crowd, preferring to stay indoors,
becoming irritable whenever there are guests in their house, avoiding other people and at times seen
staring blankly. The patient’s sister claimed that she only noticed these behavioral changes 5 months
after the patient gave birth to her 4th child. Patient’s older sister remembers her to have a happy
disposition - talkative, having a jolly demeanor. According to her, the husband noticed that the patient had
become fond of reading the bible and sometimes read it out loud. He also said that the patient was
sometimes paranoid, telling him that she hears a man’s voice telling her, “naay mupatay nako”, as
verbalized by the patient. There was also an instance when the patient pointed at a calendar and said,
“naay petsa na mamatay nako.” The patient’s sister also noticed the patient talking to herself, “mag-
english English na siya kalit, mangadyi unya kung makakita namo magsturya sturya muapil jud na siya
unya magtuo siya na gilibak kuno namo or siya ang giisturyahan” as verbalized by the patient’s sister.
They also noticed that the patient would shift from one task to another without completing the previous
one. At one time, the patient was seen by herself in the hammock. When her sister approached her, she
was muttering “kakapoy na sigeg panganak”. The patient’s sister noticed that the patient no longer
engaged in conversations unlike before. No consult or intervention was done.
In the interim, the sister claimed that the patient’s unusual behavior persisted. She however mentioned
that she only has a vague idea about the patient’s progression of behavioral changes because her sister
is residing on another island and would only receive calls from the patient’s husband. Her sister also
claimed that the patient would skip meals and lacked the initiative to feed her children. There was also a
decrease in self-awareness as to appearance and hygiene, as claimed. She was accused by the patient
to be her husband’s mistress. Her sister also mentioned that the patient did not sleep, verbalizing that,
“dili jud na siya matulog. Maglingkod ra na siya, magtanga. Usahay mamukaw na siya sa mga matulog,
pero dili jud na siya matulog. Inig buntag, kapoy na na siya, pero di gihapon katulog.” When asked what
the patient usually does at home, sister stated that patient would just sit or watch TV. She no longer
cleans the house, bathes her children, brings them to school or cooks. However, when asked if patient
takes a bath regularly, the patient said, “O, maligo jud ko taga buntag. Naligo gani ko gabii.” The
symptoms still persisted prompting the family to seek consult at a traditional faith healer initially then to
the municipal health officer, “nagpa-bisaya mi una pero wala man gihapon epekto mao na niadto mi ug
doktor sa munisipyo unya gi tagaan ra siya tambal pangkatug, wala rapud ni ingon ang doktor kung na
unsa siya pero kato nitumar siya sa tambal makatugon pud hinuon siya.” Patient was given take-home
medications, name unrecalled, with no relief of symptoms, as claimed.
One month prior to consult, patient started becoming violent, punching her husband, accusing him of
seeing other women. When asked why, she replied, “Kay feeling nako di ko importante unya magselos ko
kay naa jud koy kutob na naa siya’y lain. Kalit ra mawala sa balay unya dili ko atubangon kung naa ko
isturya niya.” Patient then gave birth to her fifth child, planned, as claimed by the couple. A few weeks
later, patient was noted to be crying frequently. Her sister noted that the patient would cradle the infant in
her arms but would not feed her. “Kung muhilak ang bata, mu-hilak sad siya og apil. Dili man niya pakan-
on murag makalimot siya.” as verbalized by the patient’s sister. Patient continued having poor appetite,
eating only when spoonfed. Persistence of patient’s symptoms caused a strain in her relationship with her
family, as claimed.
Five days prior to consult, patient’s sister took the patient’s newborn from her due to her inability to look
after her children, saying, “Maluoy man gud mi sa bata, dili ma-atiman. Makalimtan niya ug pakaon.” This
caused agitation and upset on the patient’s part, demanding them to return her baby to her care.
Night prior to consult, patient’s sister was staying over at the patient’s house. Patient started hitting her
husband when she woke up without him beside her. “Iya ra gi-pugngan ug gi-gakos pero gi sipa sipa
gihapon siya unya sige ug ingon na nakig-kita daw siya og babaye sa gawas.” as verbalized by the
patient’s sister. She tried to intervene but instead got hit by the patient. “Nagisi gud akong tshirt unya nag-
ingon ingon siya na kabit daw ko kay ngano daw gi-depensahan nako iya bana. Mao na ana ko ngano
mangabit man ko na minyo naman ko.” This was the first time the sister witnessed the patient hit her
husband, thus decided to seek consult at VSMMC-CBS.
Patient had no prior psychiatric consult done. No known psychiatric history. Patient has no suicidal or
homicidal ideations, she also said, “kay naa man ko mga anak.” Patient is not a known hypertensive,
diabetic or asthmatic. Patient has no known food and drug allergies. Previous surgery when she was 4
years old on her right hand following a swimming incident, one prior hospitalization, year and reason for
admission unrecalled.
Substance Use/Abuse
Patient is a non-smoker, non-alcoholic beverage drinker and denies any history of illicit drug use such as
marijuana and methamphetamine.
Family History:
Patient has no known family history of psychiatric illnesses. When she was ten years old, her
mother died due to a motor vehicular accident, alongside with her younger sibling. The patient’s
father, a fisherman, became an alcoholic after the incident, becoming violent towards his
children. He now has a new family and no longer
Patient’s sister claims not to have any psychiatric illness noted within the family. Patient’s
mother died when she was ten years old due to an accident involving a truck and it’s cargo
falling on them as the patient’s sister vaguely recalls. The father, who works as a fisherman, no
longer maintained close ties with them as he now has his own family. But sister recalls him to be
greatly affected by his wife’s death to the point that he became an alcoholic, returning home
drunk and getting aggressive with them with instances wherein he would hit them. Patient and
sister no longer have any contact or form of communication with their father. Patient has 7
siblings but only 3 remain. The first 2 siblings as recalled by the sister died because “ Gi kuha
man daw toh sila ug enkanto.” Followed by the accompanying sister, and then the patient who is
the fourth child. The fifth sibling died during her early childhood allegedly due to ‘convulsions’ as
the sister claims. The sixth sibling died alongside their mother in the accident. And the youngest
sibling remains in Bantayan as a housewife. Due to the death of their mother the remaining
three siblings were separated, distributed among relatives. At ten years old the patient was
taken under the care of their ‘tiya’ along with her younger sibling while the older sister was put
under the care of their grandmother living in another island. Both guardians were reportedly kind
as claimed by the sister but she did not have any knowledge as to how the patient was treated
during their separation. They were not able to have constant communication and would remain
separated for years until adulthood without knowing the condition of each other. Patient has no
knowledge of any heredofamilial diseases.
Menarche was at 11 years old, with regular cycles, lasting about 7 days, uses 3 fully soaked cloths used
as sanitary pads, with no associated dysmenorrhea. Coitarche was at 14 years old. No history of
contraceptive use. No history of STIs. She is a G6P5(5015).
G1 Abortion 2008 -- -- -- -- --
Patient claims not to have any knowledge of her parents’ age when they were pregnant with her
nor if she was a planned or normal pregnancy. When asked about her childhood development
patient would reply “Ambot basta okay raman ko.” Sister claims that developmental milestones
were at par with age. No learning or hearing disabilities were noted. Patient was only able to
reach Grade 4 but stopped after the death of her mother, she was greatly affected because they
had a very close relationship. She lost interest in going to school in the process yet does not
express any regret in doing so. Patient’s sister does not have any knowledge of the patient’s
history of any physical or sexual abuse. In adolescence, patient was allegedly a very talkative,
hardworking, generous and happy person as the sister recalls. She had her first sexual
relationship at 14 y.o. Patient now is a 27 y.o married housewife who previously worked as a
“labandera”. Husband works as a ‘trisikad’ driver or delivery and provides the financial aspect of
the family. Patient claims they had neither problem in terms of money nor scarcity of food. She
also stated when asked, that husband would take part in caring for their children and was not
negligent in his duties as a father. Sister claims that husband was not abusive to the patient and
that he would not fight back whenever the patient would attack him. He would hug the patient or
try to calm her down during these events. Patient has 5 children and only the eldest child was
planned. She also had 1 history of miscarriage. Sister claims it was before her 5 current children
were born. That event affected the patient greatly wherein she was noted to be “mag luya”,
having a hard time moving on but resolved when their eldest child was born. Patient lives in a
one story house made out of bamboo near the sea. The family sleeps on the floor and does not
have a CR. Patient would just wrap any bodily waste in plastic and throw it away. Water source
was the local municipality’s tank. Family would bathe just outside their front door using a bucket.
Good electricity. House was noted to be located in an isolated area surrounded by soil and
greenery.
Sexual History:
Patient is a heterosexual female who had her first sexual intercourse at 14 y.o. with a live-in
partner. The patient would reply “ambot niya.” when she was asked how old he was when they
started living together. Patient’s sister had no knowledge as to how she was treated under his
care but recalls “ buotan man daw toh siya pero kawatan lang. Mag cge ug inom. Mao na
nagbulag ra sila kay mag cge man pangayu ug kwarta.” She did not know if the patient
experienced any form of abuse during their one year of living together. Her second partner is
her current husband whom she had been with since she was sixteen y.o and got married 1-2
years after as the sister claims.
Physical Examination
The patient was examined conscious, sleepy, ambulatory, and not in respiratory distress with vital signs
as follows: BP 110/70 mmHg, PR 88, RR 18, Temp 36.3’C and anthropometrics as follows: Ht: 5’1” Wt
65kg BMI of 27.
HEENT: Anicteric sclerae with slightly pale palpebral conjunctiva, nasal septum at midline, no naso-aural
discharges, no tragal tenderness, moist lips and mucosa with no ulcerations
Neck/ Lymph Nodes: Supple neck, no lymphadenopathies, no neck vein distention, trachea at midline,
no neck masses
Chest and Lungs: Equal chest expansion, clear breath sounds, equal tactile fremitus, resonant on
percussion
Cardiovascular: Adynamic precordium, distinct heart sounds with normal rate and rhythm, PMI at 5th
ICS, no murmurs, heaves or thrills
Neuroexam: GCS 15, 5/5 motor strength on all extremities, able to smell, intact EOMS, 2/2 ERTL, intact
facial sensory, no facial asymmetry, able to hear on both ears equally,
CLINICAL FORMULATION
This disease was primarily considered since the patient has symptoms for Manic Episode according
to the DSM-5 Diagnostic criteria and had psychotic instances a year prior to her admission. Patient’s
symptoms was noted a year ago wherein she was noted to prefer to isolate herself wherein also she
verbalized that she had auditory hallucinations about her death in which she became paranoid about it.
Patient was also noted to talk spontaneously about random things and also noted to be talking to herself
more than the usual. Patient was also noted to be easily distracted as she starts a random task without
finishing it. Patient was also noted to be in irritable mood that she’s not welcoming anymore whenever a
visitor came to their house as compared to her previous personality and also she constantly thinks of her
husband having a mistress and became aggressive/hostile against her husband. Patient was also
observed to have a decreased in sleeping time and decreased in appetite. Patient started to don’t do her
responsibilities as a mother. Patient then was noted to be in depressed mood as she was observed to be
crying more than the usual a month prior to admission. Patient was then noted to be in
aggressive/irritable mood five days prior to admission and a night prior to the admission as she was
observed to attack her husband thinking that her husband had a mistress which is not true as claimed by
the patient’s SO. Patient denies of any smoking, alcohol drinking and illicit drug use. Patient denies of any
During the interview and mental status examination, patient’s mood was variable as she was noted
to be agitated and demanded to go home, and had crying episodes. She was also noted to be easily
distracted, also has a brief eye contact when spoken to, poor comprehension, concentration, insight and
IN OUT
energy, lasting at least 1 week and present most of the day, nearly every day
three (or more) of the following symptoms (four if the mood is only irritable) are
behavior.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
activity).
1. Schizoaffective Disorder
(insert here)
OUT
schizophrenia.
Depressed mood.
the illness.
C. Symptoms that meet criteria for a major mood episode are present for ✓
the majority of the total duration of the active and residual portions of the
illness.
2. Schizophrenia
Out
A. Two or more of the following, each present for a significant portion of
time during a 1-month period (or less if successfully treated). At least one
1. Delusions ✓
2. Hallucinations
3. Disorganized Speech
avolition).
B. For a significant portion of the time since the onset of the disturbance, ✓
prior to the onset (or when the onset is in childhood or adolescence, there
occupational functioning.
experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with ✓
the active-phase symptoms, they have been present for a minority of the
condition.
successfully treated).
In
A. Five (or more) of the following symptoms have been present during the
least one of the symptoms is either (1) depressed mood or (2) loss of
most of the day, nearly every day (as indicated by either subjective account
or observation)
3. Significant weight loss when not dieting or weight fain (e.g., change or
may be delusional) nearly every day (not merely self-reproach or guilt about
being sick)
committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, ✓
include the feelings of intense sadness, rumination about the loss, insomnia,
poor appetite, and weight loss noted in Criterion A, which may resemble a
judgment based on the individual's history and the cultural norms for the