1

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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Bed Site Teaching
A 40 years old man was admitted to General Centre Hospital Dr. M. Djamil Padang Polyclinic
on July 16
th
, 2014 at 10.30 p.m.with his family. This patient feeling was sick because he can see
something that another people cant see, feeling alone and think every people is lier. This is his
first visit to psychiatry polyclinic.
Patient identity:
Name and Age : Ny. NLN/ 24 years old
MR :
Gender : Female
Place and date of birth :
Marital status : Married
Address :
Occupation/School : Jobless / graduated from Vocation High School
Religion : Islam
Citizen : Indonesian
Tribe : Minangnese

A. Internal Status
General appearance : Compos Mentis
Blood pressure : 110/80 mmHg
Pulse : easily palpable, regular, 84 x per minute
Respiration : abdominothoracal pattern, regular, 20x per minute
Temperature : 36,8
0
C
Height :
Weight :
Cardiovascular system : No abnormality detected
Digestive system : No abnormality detected
Specific disorder : No abnormality detected

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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 23
th
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 5
th
because patients
family havent enough money for school

Social economy history
Living 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 was not 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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Marital History
Patients was married two times
2011 : he was married when she was 21. Have no children and divorce in 2013 because his
husband dont like her act.
2014 ; he is married for second time when she was 24 years old. She is 7 months old
pregnant now.
Family history of illness








Note:
: patient

: women

: man

: man who had same illness like patient


There was family members that has same symptoms like this which is patients uncle.




?
7

Graphic of illness




Auto-history taking, July 23
th
2013 :
Questions Answers Interpretation
Assalamualaikum Pak. Saya
dokter muda Farhan dan
Rahmat, boleh kami ngobrol
dengan bapak?
Waalaikumsalam, boleh dek.
Mau ngobrol apa?


Cooperative

Nama bapak siapa?

Umur bapak berapa?

Saya Pak Khairul Yahya.

Sekarang saya 40 tahun
Pak, kalau boleh tahu kenapa
bapak bisa sampai di rawat
disini?
Iya, saya sendiri yang ingin di
rawat. Saya meminta keluarga
saya untuk membawa saya
kemari dek. Saya merasa
emosi saya meluap-lupa terus,
jadi saya ingin dirawat untuk
dapat obat penenag dek. Terus
saya juga malas makan
semenjak emosi saya ini
menjadi- jadi dan saya gak


Discriminative Insight tidak
terganggu
2011 2012 2010 2011 2012 2013 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 itu
dan 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 tidak
dekat 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 salah
tahun 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 takut
saya 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-bakar
sesuatu 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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O iyo pak. Coba tolong Buat
gambar agak satu. Trus
menulis disini
Oh jadih
Ini dek uda siap

Bapak masih ingat nama saya
dan kawan saya?
Masih. Dokter farhan sama
rahmat
Memory is good
Oke pak, makasih banyak ya Iyo sama-sama dek

EXPLANATION AND CONCLUSION OF PSYCHIATRIC EXAMINATION
Examination is on July 23
th
2014, 01.45 p.m WIB
1. General appearance
Consciousness/sensorial : compos mentis/good
Attitude : cooperative
Motoric : active
Facial expression :
Verbalization : speak not clearly and not fully understood
Physic contact : couldnt be done / inappropriate / a while
Attention : not good
Initiative : none
Specific condition
A. Affective
1. Affective condition : hypotim
2. Emotional :
a. Stability : instable
b. Control : not good
c. Echt/unecht : unecht
d. Einfuhlung : inadequat
e. Deep/shallow : shallow
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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, couldnt speak
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 was not 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 couldnt be done
Occupatinal couldnt be 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