bipolar affective disorder, manic episode with psychotic
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MUHAMAD AZRUL 0810314158CHARAN PAL SINGH 0810314156
PRECEPTOR:dr. YASLINDA YAUNIN SP. KJ
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Name : Sari Bulan Gender : Female Age ` : 29 years old. Marital status : single Address : koto Napan, Sumut Occupation and School : Secondary school,
not working Religion : Islam Citizen : Indonesian Race : Minangkabau
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A 29 year old female patient was admitted to RSJHB Saanin emergency department on April 26th,2013 and escorted by her brother. This patient
presented with signs such as anxiety, alwaysbeing angry without reason, always talking toherself without sense, laughs herself even whenthere is no one around, sometimes she becomes
emotional when things doesnt go on her needs..She has delusion of greatness and thinks she is afamous artist. She has no problem in her eatinghabits. She threatened her family members with
harsh words
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Internal Status
General appearance : Compos Mentis
Blood pressure : 110/70 mmHg
Pulse rate : 86 x per minute
Temperature : 36,5 C
Cardiovascular system : No disorders found
Digestive system : No disorder found
Specific disorder : No disorder found
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Neurological Status
GCS 15, pupil reflex positive, corneal reflex positive
No meningeal signs, no signs of increased intracranial pressure
Cranial nerves : No disorders found
Motoric : Eutonus, Eutrophic, no disorder,
Muscle strengthsuperior extremity 555/555,
inferior extremity 555/555
Sensibility : No disorder foundSpecific disorder : No disorder found
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ALLOANAMNESIS
Was done on 20th May 2013
Alloanamnesis obtained from patients brother:
Name : Salam
Age : 44 years
Telephone :
Work & Education : private company
Relation with patient : brother
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1.
Main reason of HospitalizationThis patient presented with signs such as anxiety, always being angry without reason,
always talking to herself without sense, laughs herself even when there is no one around,
sometimes she becomes emotional when things doesnt go on her needs.. She has
delusion of greatness and thinks she is an famous artist. She threatened her family
members with harsh words
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Present complaint of Illness
Patient classified as Healthy without any complaint
1. History of IllnessYear 2006 (Month unidentified)
Patient was frequently anxious; always get angry if her need doesnt go with her desire.Always goes out during the night, threaten her family members with harsh words and was
brought to the RSJ HB Saanin and was admitted
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Year 2007-2012 (month unidentified)
The patient was admitted regularly to the hospital for the same complaints She was
brought to RSJ HB Saanin and was warded there. She has been in and out of the hospital
for the past 6 years with the same complaints
Year 2013 (April till Present)
Patient does not want to take regular medications, laughs without any reason, she has
delusions of greatness as if she is a famous celebrity. The patient likes shopping. The patients
also thinks she has graduated from university and obtained a degree.
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3. Premorbid History
Infant : born spontaneously, birth wasassisted by midwife, no history of jaundice,
cyanosis, or seizure.
Childhood : growth and development suitablefor her age.
Adolescence: polite, had a lot of friends, easilymake new friends and outgoing person
Adult : have a lot of friends
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4. Educational Background
Primary School : completed primary school
Secondary school : completed secondaryschool
5. Work history
Patient has no working history
6. Socioeconomical status
Lives with her elder brother in a permanenthouse, good electricity and water resources,with a color TV and motor vehicles.
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1. Family History
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Graphic of illness course
Years
20102012
2006 20112007 2008 20092013
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Summary of Phsyciatric Examination
I. General Appearance
Counciousness : compos mentis
Attitude : cooperative
Motoric : active
Facial expression : good
Verbalization : can talk, clearly and fluently
Physic contact : can be done, appropriate, long enough
Attention : present
Initiative : present
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II. Specific Condition
A. Affective
1.Affective condition : hypertym2. Emotional :
a. Stability : stable
b. Control : controlled c. Echt/unecht : echt
d. Einfulung : inadequate
e. Deep/shallow : shallow
f. Differentiation scale : narrow g. Emotional flow : slow
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B. Intellectual condition of function
a. Memory : enough
b. Concentration : enough
c. Orientation : time orientationgood, special and persons orientation good
d. Knowledge : undetermined
e. Discriminative insight : not disturbed f. Intelligence prediction : average
g. Discriminative judgment : notdisturbed
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C. Sensation and perception abnormalities
1. Illusion : none
2. Hallucination :
Acoustic : none
Visual : none
Olfactory: none
Tactile : none Gustatory: none
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D. Thought process condition
1. Speed of thought process :clear andappropriate
2. Quality of thought process:
a. Clear and sharp :clear and sharp
b. Incoherent : none
c. Sperrung : none d. Hemmung : none
e. Flight of ideas : present
f. Verbigeration : none
g. Preservation : none
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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 : little
j. Feeling guilty : none k. Hypochondria : none l. Others : none
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E. Instinctual drive and behaviorabnormalities a. Abulia : none
b. Stupor : none c. Raptus/impulsivity : none d. Excitement state : none e. Sexual deviation : none f. Echopraxia : none g. Vagabondage : none h. Pyromania : none i. Mannerism : nonej. Others : none F. Over anxiety : none G. Reality testing ability : no disturbance
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MULTIPLE AXIS RESUME
Axis 1. Clinical syndrome
Patient does not want to take regularmedications, laughs without any reason, shehas delusions of greatness as if she is afamous celebrity. The patient likes shopping.The patients also thinks she has graduatedfrom university and obtained a degree.
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Phyciatric examination
General condition: compos mentis,
cooperative, less initiative, hyperactive,verbalization is clear and sharp,talkative,psychic contact good, appropriate, longenough.
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Specific condition :
1.Affective condition: hyperthym, stable, echt,
2.Intellectual condition of function: memorygood, good concentration, time orientation isgood, knowledge is difficult to evaluate,discriminative insight not disturbed,
intelligence average, discriminative judgmentsnot disturbed.
3.Sensation and perception abnormalities: noillusion ,no hallucination,
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4.Thought process condition: fast, clear andsharp, circumstantial present, delusional,suspicious.
5.Instinctual drive and behavior abnormalities :no disturbance
6.Over anxiety : none
7.Reality testing ability : nodisturbance in behavior, feeling and thinking
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Axis II. Personal disorder and mentalretardation disorder
Personality disorder : none Mental disorder : none
Axis III. General medic condition
No history of head trauma , or malaria whichneeded hospitalization.
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Axis IV. Psychosocial stressor and environment
None
Axis V. Global assessment functional Social: likes shopping and going out at night
Daily Activity: no disturbance.
Leisure/ recreational activity: no disturbance.
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Multiple Axis diagnosis
I . F31.2 Bipolar Affective Disorder, ManicEpisode with psychotic symptoms
II. No Diagnosis III. No Diagnosis
IV. No problems
V .
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Differential diagnosis
F 31.8 Other Bipolar Affective disorders
F 06.31 Organic Bipolar Affective disorder
Therapy
- Chlorpromazine 1 x 1 tablet @ 100 mg
- Risperidone 1 x 2mg
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Prognosis
Clinical : dubia ad bonam
Functional : dubia ad bonam
Social : dubia ad bonam
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Autoanamnesis
Dokter Muda Pasien Interpretation
Sore kak
Perkenalkan nama saya dokter
muda Azrul dan ini teman saya CP
Bisa kami bertanya ke Bulan?
Lagi ngapain tadinya?
Udah makan?
Tau Bulan dimana sekarang?
Udah berapa lama disini?
Kenapa bias sampai disini?
Baa tu?
Sering ngak kedengaran suara
suara, bisikan, Nampak bayangan,
mencium bau?
sekolah sampai kelas berapa
bulan?
Tinggalnya sama siapa bulan?
Sore doc
Nama saya Bulan. Teman kamu
ganteng sekali, hidungnya mancung
Bisa abang
Baru selesai mandi
Makan siang alah, makan malam
alun
Tau, lagi di rumah sakit
Udah hampir 1 bulan
.
Saya sakit jadi dihantar sama
keluarga berobat
Tidak ada bang
.
Saya kuliah ambil S.Pd tapi berhenti
sampai semester 4. Tidak bias
belajar,susah.
Tinggal sama keluarga bang.
Cooperatif
Orientation is not
disturbed
Discriminatifinsignt is good
Discriminatif
judgement is
good
No hallusination
Delusion
Concentration is
good
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