bst dr. linda, eta jonni
TRANSCRIPT
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BIPOLAR AFFECTIVE
DISORDER
Dilla Mareta Amenike (RP. 429)
Rahendra Wijaya Jonni (P.826)
PERCEPTOR :
Dr. Yaslinda Yaunin, SpKJ
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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.
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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
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ALLO-ANAMNESIS
Name/Age : Armen Filma/40 years old
Address : Sungai Penuh, Kerinci (0811742897)
Occupation : Trader
Relationship with patient : Older Brother
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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
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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
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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
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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
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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.
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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.
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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.
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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.
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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.
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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
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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
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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.
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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
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FAMILY HISTORY
♂ ♀ ♂ ♀
♂ ♀ ♀ ♂ ♂ ♂ ♀ ♂
♀ ♀ ♂ ♀ ♀ ♀ ♂ ♂
There were no family members that has same symptoms likethis.
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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
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AFFECTIVE
Affective condition : hypertim
Emotional :
Stability : stableControl : good enough
Echt/unecht : echt
Einfuhlung : inadequat
Deep/shallow : shallow
Differentiation scale : narrow
Emotional flow : fast
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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.
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DIFFERENTIAL DIAGNOSIS
F 31.6 Bipolar Affective Disorder Mixed Episode
F 25.0 Manic type schizoaffective
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THERAPY
Risperidon 2 x 1 mg
Haloperidol 2 x 5 mg
THP 2 x 2 mg
Education to the family
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PROGNOSIS
Clinical : dubia at malam
Functional : dubia at malam
Social : dubia at malam