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Bed Site Teaching

Gangguan Afektif Bipolar Episode Kini Manik dengan Gejala Psikotik

OLEH

FARHAN NAZIR P.1422

RAHMAT FERYADI P.1428

PEMBIMBING

dr. Yaslinda Yaunin, Sp.KJ

BAGIAN PSIKIATRI

FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS

RSUP DR M DJAMIL

PADANG

2014


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B. Neurological Status

Cranial Nervous (five senses) : Vision, smelling, hearing, tasting, and tactil are 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

- 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

- Rigid : None

- Tremor : None

- Nasal Stiffness : None

- Oculogyric Crisis : None

- Torticolis : None

-

Others : None


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Allo-history taking:July 23th

2014

a.Name and age :

b.Address : Alai Barat Street, No. 25, Parak Kopi, North Padang

c. Phone Number : 085272221553

d.Occupation : Housewife

e. Education : Junior High School

f. Relationship : Wife

Primary cause of hospitalization

The patient was admitted to M. Djamil Hospital because prick her mother, threw glass and

plate at home

History Illness

2011 : Patient was firstly married after graduated from high school. After maried they

lived in Duri. Problem came when her husband not care anymore, he is busy with his job and

come home rarely. Since then, patient always sad, like to be alone and iritable. Her husband

took her home in Suliki. At her parents home she start act bizzare like naked inside the

house, talking with nobody, laughing by herself, pulling her hair and so on. Her parents took

her to the paranormal, after the medication she feel helathy and could do normal activity. She

came back live with her husband in Duri for 4 months but next 2 months she act bizzare like

the old day because she is jealous with a woman who close with her husband. She came back

home to her parents home and their parents took her to the psychiatrist in Bukittinggi and got

prescription but she is not obey to took the medicine.

Patient went to Puskesmas and given 3 drugs. After consuming the drugs the patients

getting better and act like normal people. She could talk to others and could do the activity

well. When the drugs is run out, she went to midwive to get the drugs, but the midwives

change the drugs after that there are so many blister on her whole body, her lips exfoliate and

became darker. Since then she stopped consuming the drugs. She start acts bizzare like the

old day before she took medication like iritable, talking alone, laughing by herself.


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2014 :On the early January, patient got a job at a shop as a servant. In that shop, she

open her ex husband profile facebook. Since then she became sad, agitation, walking outside

the house without destination. She dont want eat and sleep. She talking alone and laughing

alone, prick her mother if their wants not realised. She like play with fire and burn something

thet interest her such as paper. She like sharp tools such as knife but didnt harm other

people.

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 : she is not going to the college because someone proposed her

Educational background

Elementary School at SD N 21 Indrapura, not graduate, just reach levl 5th

because patients

family havent enough money for school

Social economy historyLiving with his parents, had a semipermanent house, had a TV and electricity on it, water

supply from National Water Company, had no home-phone.

Biological development background

Head traumas history wasnot present,

No history of malaria, typhoid, or brain and neurological disease

No Alcohol history and addicted drugs

Occupation History

Patient work as a servant in a shop a week at January 2014


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bisa tidur dek.

Oh begitu, memangnya sejak

kapan emosi bapak menjadi

meluap-luap?

jadi ceritanya gini dek, 1

minggu yang lalu ada kawan

dekat saya yang diancam sama

orang Aceh tetangga teman

saya ini. Dia memang

lawannya teman saya dek. Jadi

saya sebagai temannya merasa

marah karena dia diperlakukan

seperti itu, mulai saat itu saya

rasanya mau berantam saja

sama orang tersebut biar saya

lega dan emosi saya bias turun

dek

Terus pak puncak emosi bapak

itu kapan?

Memangnya arti teman buat

bapak itu seperti apa?

Terutama teman bapak yang

satu ini

Ya pas sebelum saya masuk

dek. Saya melihat teman saya

itu dikeroyok dengan orang-

orang yang mengancam itudan saya rasanya mau

memukul mereka dek. Jadi

saya ambil balok dan golok

dek untuk menakut-nakuti

mereka.

Dia itu teman kecil saya.

Sebenarnya saya sudah tidakdekat dengan dia karena dia

nakal. Tapi kemaren itu dia

mau bertobat makanya saya

mau berteman lagi. Makanya


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ketika ada yang ganggu dia

saya sangat marah dan

emosian.

Oh begitu, terus bapak ada

mendengar suara-suara ga

sebelum ngamuk-ngamuk

seperi itu?

Kalau melihat sesuatu

bayangan?

Kalau mencium bau busuk,

bau kemenyan?

Kalau merasa seperti ada yang

memegang dan menyentuh

bapak?

Gak ada dek

Gak ada juga

Gak ada dek

Gak ada juga dek

Halusinasi tidak ada

Ooo jadi bapak memang

seringnya emosinya meluap

dan suka ngamuk-ngamuk

seperti itu?

Ya dek saya gk ngerti juga

kenapa bias seperti itu

Bapak sebelumnya pernah

mengalami hal seperti ini

juga?

Pernah dek sekitar 6-7 tahun

yang lalu

Bapak sampai dirawat karena

hal itu?

Pernah dek. Saya dirawat di

RSJ Gadut kalau gk salahtahun 2008 dek

Kenapa bapak dirawat? Atas

keinginan sendiri atau gimana

Iya de katas keinginan sendiri,

saya merasa butuh penenang


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pak? makanya mau dirawat. Disana

saya dirawat selama 3 hari

Lalu? Terus saya dipulangkan

dengan obat pulang dan

disuruh rutin control dek

Berapa lama bapak makan

obatnya? Setelah habis obat

bapak rutin control?

Obatnya habis 6 bulan dek

siap itu saya gk control lagi

karena merasa sudah tenang

dek.

Ooooo. Selain tahun 2008

itu pak, kapan lagi bapak di

rawat?

Hmm tahun 2009 dek. Di

RSJ Gadut juga.

Bapak kesana atas keinginan

sendiri lagi? Dirawat berapa

lama pak?

Ya dek, atas kemauan saya

sendiri. Saya disana hanya 3

hari, tapi keluarga saya

menjemput saya pas hari ke 17

dek karena keluarga saya takutsaya nanti masi sering

ngamuk-ngamuk kalau dibawa

pulang.

Bapak pulang dikasih obat

juga? Di anjurkan control?

Iya obatnya untuk 6 bulan

jugak dek dan saya gak rutin

control juga siap habis

obatnya.

Kalau kita boleh tau pak,

penyebab bapak ngamuk-

ngamuk dan emosian pas dulu

Kalau di tahun 2008 saya

sudah tidak ingat dek. Tapi

yang dirawat tahun 2009 saya


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itu apa ya pak? di rawat karena masalah

kerjaan saya dek, saya merasa

dibohongi

Bapak pernah ngerasa rendah

diri nggak?

Bapak pernah juga gak ketika

dulu mengalami kesedihan

yang mendalam, rasa tidak

berguna, pokoknya yang

sedih-sedih gitu pak?

Nggak dek. Gk pernah.

Sehari-hari saya aktif dek.

Saya malah selalu percaya diri

dek

Gak pernah dek. Saya happy

terus. Cuma saya juga gak tau

kenapa terkadang emosi saya

meluap-luap

Inferior Feeling is absent

Depreesion feeling is absent

Hubungan bapak sama

keluarga seperti apa?

Sampai saat saudara-saudara

saya tidak ada yang

menjenguk saya. Di tahun

2008 dan 2009 saya sempat di

pasung selama 4 hari karena

ngamuk-ngamuk makanya

saya lebih baik dirawat. Tahun

2014 ini juga saya setelah

keroyokan itu sempat di

pasung juga dek.

Oooo. Bapak ada cita-cita

yang gak kesampaian gak?

Dulu ada dek. Saya dulu ingin

sekali jadi tentara tapi tidak

kesampaian. Sekarang gk ada

lagi cita-cita seperti itu

Obsession is absent

Bapak ada ngerasa curiga gk Saya gak pernah ada curiga Suspicious is absent


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sama oarng-orang sekitar?

Kalau rasa dendam gitu pak?

Cemas-cemas pak?

sama orang dek

Dendam juga gak ada

Repulsions is absent

Over anxiety is absent

Bapak ada merasa bersalah

gak pak setelah semua

kejadian ini?

Iya dek. Ada. Saya merasa

bersalah dan saya takut kalau

keponakan-kepoakan saya tau

akan kejadian ini dan ikut

terlibat nantinya dek.

Feeling guilty is present

Jadi sekarang bapak ngerasa

ada sakit gak?

Saya merasa emosi saya tidak

terkontrol makanya saya mau

disini dirawat biar tenang

Discriminative insight not

disturb

Pak, hari ini hari apa? Rabu Time Orientation is good

Tanggal? 23 Juli 2014 Time Orientation is good

Place Orientation is good

Personal Orientation is good

Ini dimana sekarang? Di rumah sakit M Jamil dek

Tau Presiden sekarang siapa?

Presiden yang baru menang

pak?

SBY

Jokowi dek

Bapak suka pergi jalan-jalan

sendiri? Ngak tentu arah.

Ndak sadar dimana

Nggak ada dek Vagabondage is absent

Bapak suka mambakar-bakarsesuatu gitu gak?

Nggak kok. Pyromani is absent

Pak ada merasa takut-takut

gitu gak?

Gak dek, saya gak ada takut

sama apapun dek

Phobia is absent


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f. Differentiation scale : narrow

g. Emotional flow : slow

B. Intellectual condition of function

a. Memory : not good

b. Concentration : not good

c. Orientation : not good

d. General and schooling knowledge : couldnt

e. Discriminative insight : disturbed

f. Intelligence prediction : average

g. Discriminative judgment : disturbed

h.

Intelectual deterioration : none

C. Sensation and perception abnormalities

1.Illusion : none

2.Hallucination :

Acoustic : exist

Visual : exist

Olfactory : exist

Tactile : none

D. Thought process condition

1. Speed of thought processs : slow

2. Quality of thought process:

a. Clear and sharp : not clear and not sharp

b.Circumstantial : none

c. Incoherent : exist

d.

Sperrung : none

e. Hemmung : none

f. Flight of ideas : none

g.Verbigeration : none


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h.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 : none

i.

Much/little : much

j. Feeling guilty : present

k.Hypochondria : none

l. Others : none

E. Instinctual drive and behavior abnormalities

a. Abulia : exist

b.Stupor : none

c. Raptus/impulsivity : exist

d.Excitement state : none

e. Sexual deviation : none

f. Echopraxia : none

g.Vagabondage : none

h.Pyromania : none

i. Mannerism : none

j.

Others : none

F. Over anxiety : none

G. Reality testing ability : not disturb in attitude, thought, feeling


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MULTIPLE AXIS RESUME

Axis I. Clinical Syndrome

The patient

Phsyciatric examination:

General Appeareance: compos mentis, cooperative, active, poor facial expresion, couldntspeak

clearly, psychic contact could be done, inappropriate and a while.

Specific condition:

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

b. Intellectual condition and function: good memory, concentration good enough, good

orientation, schooling and general knowledge good enough, intellectual deterioration not

disturb, discriminative insight and judgement not disturb.

c. Sensation and perception abnormalities: no illusion, acoustic, visual, tactil and olfactoric

hallucination present since childhood.

d.

Thought process condition: fast, clear and sharp enough, much.

e. Instinctual drive and behavior abnormalities: none

f. Overt anxiety: none

g. Reality testing ability, not disturb in attitude, thought, feeling

Axis II : Personality Disorder and Mental Retardation Disorders

Personality: outgoing, has a lot of friend

Mental retardation: none

Axis III : General Medical Condition

Head traumas history wasnot present


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No history of malaria, typhoid, or brain and neurological disease

No history consuming alcohol and other addictive drugs

Axis IV : Phsychosocial Stressor and Environment: Not consuming drugs anymore

Axis V: Global Assessment of Function

Social relationship couldntbe done

Occupatinal couldntbe done

Spending time with watching TV, travelling, could be done

MULTIPLE AXIS DIAGNOSIS

I. F.31.2 Bipolar Affective Disorder Manic Episode with Psychotic Symptoms

II. No Diagnosis.

III. No Diagnosis

IV. No Diagnosis

V. GAF 90-81.

DIFFERENTIAL DIAGNOSIS

I. F 25.0 Manic type schizoaffective

II. F 31.8 Others Bipolar Affective Disorder

THERAPY

Chlozapine

PROGNOSIS

Clinical : bonam

Functional : dubia at bonam


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Social : dubia at bonam

SUGGESTION FOR THERAPY

Education to the family

ECT

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