FACULTY OF MEDICINE AND HEALTH

SCIENCES
DEPARTMENT OF PSYCHIATRY UPM

PSYCHIATRY POSTING

CASE WRITE-UP 2

BIPOLAR DISORDER, MANIC EPISODE

NAME : NURNADHIRAH BT HJ ZULKIFLI

MATRIC NO. : 190386
SUPERVISOR : DR AARON FERNANDEZ
Patient’s Biodata
Name : Asyari B. Ahmad
Age : 34 years old
Gender : Male
Race : Malay
Religion : Islam
Nationality : Malaysian
Occupation : Currently unemployed
Marital Status : Single
Date of Admission : 14 October 2019
Date of clerking : 18 October 2019
Address : No 3, Jalan Seri Emas, Kajang

The informant was the patient herself. The history was reliable.

Chief Complaint
Mr A, 34 years old Malay gentleman, single, currently unemployed with underlying
psychiatry illness for the past 5 years was presented to ED Hospital Kajang voluntarily with
the chief complaint of become angry easily for 5 days, sleep disturbance for 4 days, increase
frequency of bathing, doing house chores and changing clothes for 4 days and have special
power for 4 days prior to admission.

History of Presenting Illness

He had background history of mental illness for 5 years duration. He was first diagnosed to
have psychiatry illness in a Hospital Kajang because he became aggressive and hit his brother
with baseball stick. He beat his brother because he refused to bring him to nearby restaurant.
He was given medication and discharged. He claimed that he was adherent to medication.

For this current admission, he had persistent irritable mood for 5 days ago. He was provoked
to anger by small matters. For example, if his family member tried to switch the channel
while he was watching television, he became angry and bang the table. He also quarreled
with his eldest sister frequently whenever he went back to his parents home. Besides, he also
pushed the dishes in dining table onto the floor when his father irritated him. He noticed that
his condition worsened and he knew that his manic symptoms will come back, hence he
voluntary came to hospital to seek for treatment.

In addition to that, he also had increased in frequency of bathing since 4 days ago. He bathed
at least 5 times a day. On further questioning, he does not have any recurrent thought of being
contaminated with germs. He also kept on changing his clothes in one day and keep on doing
house chores over and over again. For the past 4 days, he also claimed that he became more
confidence and believed that he able to convince other people to obey to him. He believed
that he had extra sensory ability and knew that it was gift from God. On further questioning
on how he was chosen by God, he told that the God told him in his dream every day and he
was 100% convinced about it. Previously patient told about his ability to his family members,
but they did not believe it, and this will make him become easily irritable day by day. He
claimed that he has ability to read other people mind. For example, he knew what his brother
think while he was watching television.

For the past 4 days, patient claimed that his sleep routine was disturbed as he started to work
as Grab driver at night. He started his service as Grab driver just about 2 weeks ago. He
usually will doing Grab service 3 times weekly, starting from morning till midnight. Since
than, he had decreased the need of sleep for the past 4 days. There was no difficulty in fall
into sleep but he woke up at 5am, about 3 hours earlier than usual. He felt energetic and not
easily tired after woke up from sleep. Sometimes he cannot sleep because he has many ideas
on how to increase his Grab income. However, he denied became more talkative or spent
money excessively. He also denied of increased in sexual activity. He can talk with his
friends and neighbours. He denied any symptoms of depression such as persistent depressed
mood or anhedonia. He also denied hearing of voices or seeing shadow. Beside that, he also
denied someone wanted to harm him. He also denied symptoms of hyperthyroidism such as
tremor, anxiety, increased in appetite, loss of weight, heat intolerance or diarrhea.

Past Psychiatry History

This is his 3rd admission to the ward. The 1st admission was in 2014 in Hospital Kajang and
was diagnosed as Bipolar Disorder. The 2nd admission was on September 2017 in Hospital
Kajang due to aggressive behaviour. He was not adherent to medications since early August
2017 because patient claimed he is not sick anymore. He was then discharged with
medication but patient unable to remember the medications given. However, for this current
admission, previously he missed his medications for about 1 month prior to admission
because he misplaced it because he was moving out into his rental house. Patient started to
felt unwell due to non adherent to medications and immediately went to ED to seek for
treatment. Previously he mentioned that he was on Epilim 200 mg. otherwise, there is no
history suicical and homicidal thought and no history of deliberate self harm.

Past medical and surgical history

He had no hypertension, diabetes mellitus, heart disease, asthma or brain injuries. There was
no endocrine disease such as hyperthyroidism or hypothyroidism. He never underwent any
surgery before.

Family History
3rd wife

1st wife 2nd wife

patient

His father had 3 wives. His mother was the first wife. Both of his parent was alive. His father
had hypertension and heart disease and underlying Bipolar Disorder, currently on treatment.
However he underwent bypass surgery past 2 years in Hospital Serdang. His mother had
hypertension but well controlled. He was closed to his second sister. There was positive
family history of mental illness in her family. Her uncle, aunty and cousins were suffered
from mental illness, but unsure the diagnosis.

Personal History
He was born through Caesarian delivery. There was no birth trauma. He had normal
developmental milestone as compared to his other siblings. He had no feeding and sleep
difficulties. He was an active and friendly child. However, he was sexually abuse by his uncle
when he was 5 years old several times. His uncle touches his private part. However, he never
told this incident to his parent or siblings.
He enjoyed went to school. He was active in sport and can mix well with his friends.
He had no learning difficulties in school. His performance in academic in primary school was
not very good. He was then continued his studies in Kolej Vokasional Sepang. After
graduated from vocational school, he worked as mechanics for 3 years however stopped
working because he did not cope well with his performance and his boss stigmatized him
after being diagnosed as Bipolar Disorder. Otherwise there is underlying history of substance
use. He is non smoker and non alcoholic and never involved in high risk sexual behavior.

Current Social Situation

Currently lived in his rental room. The rental rate was supported by his family members and
his income as grab driver. Previously he lived with his parents and siblings but decided to
move out because he went to live independently and start a new job as Grab driver. However
currently was unemployed because he aware that his manic symptoms are coming. His
relationship with his friends were good. He occasionally went playing futsal with them.

Premorbid personality
He was an optimistic person. He respects his parents. He also had a number of friends. He
liked to playing futsal and badmintion with his school friends.

Mental Status Examination

General appearance
He was a adult Malay gentleman sitting on the chair during interview. There was no stooped
posture, abnormal involuntary movement. He was dressed neatly in hospital attire. Personal
hygiene and self care looks good. He looked calm and did not anxious. He was cooperative
during the interview.

Speech
He spoke in Malay fluently through out the interview. His language was understandable. The
amount and volume of the speech were normal. The tone and speed of the speech were also
normal.
Mood and affect
The mood of the patient was happy. Her affect was broad, appropriate and congruent with her
thought.

Perceptual Disturbances
There was no visual, auditory, tactile, olfactory or taste hallucination. He denied any
perceptual disturbances during the interview.

Thinking
Form
The form of thinking was meaningful. There was no loosening of association,
circumstantiality or tangentiality.
Flow
There was no flight of idea, poverty of thought or thought block.
Content
Currently patient was actively deluded as evidence that he has extra sensory ability and can
read other people mind. Otherwise no suicidal thought.
Possession
No thought insertion, thought withdrawal or thought broadcasting.

Cognition
Orientation
He remembered the time at that time, the date of that day and also morning or evening
correctly. Beside that, he also recognized himself and other patient and me as medical
student. He also knew that he was in psychiatry ward, Hospital Kajang.
Orientation: intact.

Attention and concentration

He was unable to perform the serial 7 subtraction tests but patient able count the day
backwards from Sunday to Monday.
Attention and concentration: normal
Memory
Immediate Memory and Recent Memory
He was able to recall the two of the three dissimilar objects after 5 minutes of distraction.
Objects told were umbrella, car and ball. Answers after 5 minutes were correct.

Remote memory
He was able to recall his birthday and remember the number of his identity card correctly.

Information and Intelligence

Comprehension: He could understand my questions and also me appropriately.
Vocabulary: His vocabulary was good.
He has no difficulty in arithmetic
Questions: How much you’ll get back if you gives RM 4 for a RM 3.50 Fried Rice?
Answer : RM0.50
The General Knowledge is intact
Questions: Who is our current prime minister?
Answer : Tun Dr Mahathir
Information and Intelligence: Normal

Abstract thinking
Proverb test: He knew and can explained the following proverbs:
Bagai aur dengan tebing

Test of similarity: Normal

Questions: Answer
1. What is the similarity between apple and orange? fruit
2. What is the similarity between cabbage and spinach? Vegetable

Judgment
Social Judgment: Impaired
What do you think about smoking in the cinema?
Answer: “They paid for the ticket, they can smoke.”
Test Judgment: Normal
What will you do if your house was on fire?
Answer: “I will ran away to save my live.”

Personal Judgment: Normal

What will you do if you are going to be discharged today?
Answer: “I’ll go for a long vacation.”

Insight
Patient understood and aware that he was sick and need to take any medication. He had good
insight.

Physical examination
General appearance
Mr A, Malay gentleman was sitting on the chair during interview. He was conscious and
responsive. He was not in respiratory distress. Hydration status appears to be normal.
Vital signs
Temperature : 37° C
Pulse rate : 88 beats per minute (regular in rhythm and normal volume)
Blood pressure : 126/78 mmHg
Respiratory rate : 22 breaths per minute
Examination of cardiovascular, respiratory, abdominal, central and peripheral nervous system
were unremarkable.

Summary
Mr A, 34 years old Malay gentleman, single, currently unemployed with underlying
psychiatry illness for the past 5 years was presented to ED Hospital Kajang with the chief
complaint of manic symptoms such as irritabe mood for 5 days, sleep disturbance for 4 days,
increase goal directed activity such frequency of bathing, doing house chores and changing
clothes for 4 days and delusion of grandiose for 4 days prior to admission. Mental status
examination showed delusion of grandiose, no flight of ideas, no pressured speech.
Immediate, recent memory, abstract thinking were relatively intact. Her social judgment was
also impaired. Physical examination revealed no abnormalities.
Provisional Diagnosis: Bipolar mood disorder, manic episode.
Point for:
1. Irritable mood for 5 days and hospitalization is required.
2. More confident and increased self esteem
3. Increased in goal directed activity: increased the frequency of bathing and doing
house chores.
4. Decreased the need to sleep.
5. Delusion of grandiose: He have extra power to make people obey to him.
6. History of admission to psychiatry illness suggestive of bipolar disorder : Aggressive
behavior
7. Positive family history of mental illness: His father, uncle, aunty and cousin had
mental illness.

Management :
Investigations
Biological Investigation:
1. Full Blood Count :
To look for leucocytosis because lithium can cause leucocytosis
To look for thrombocytopenia because sodium valporate can cause it
2. Liver Function Test: To assess abnormalities in liver function
3. Renal Profile: to exclude electrolyte imbalance because lithium can cause dehydration
4. Thyroid function test to rule out hyperthyroidism that can cause aggressive behavior.
5. ECG because started he on lithium as it can cause arrythmia
6. Therapeutic drug monitoring : to prevent lithium toxicity as it has narrow therapeutic
index.

Psychological Investigation:
- Young mania rating scale to access the severity of manic symptoms.

Social investigation :
Get the collaborative history from family members for :
1. Clarifying the history obtained from the patient and get more history from family
members.
2. Get the premorbid personality and past history.
 3. Check the compliance of patients to medications.
4. To assess stressors that can be precipitating and perpetuating factors for her.
5. Assess the family support.

Trace old notes to determine pattern of depressive and manic episode that may help in
management.

Treatment
Firstly, I would like to screen any risk of harm to self or to the others and screening for
suicidal risk factors. In acute phase, I will give the patients IM haloperidol and IM
Midazolam because he had irritable mood that may cause him to have aggressive behavior if
patient refuse to treatment. Besides he had psychotic symptom like delusion of grandiose as
well. However I would like to closely monitor for the extrapyramidal symptoms of
haloperidol.

In stable phase, I will give him mood stabilizer. Based of CPG Management of Bipolar
Disorder in adult, Lithium was chosen as the first line treatment. Hence I will choose lithium
as it is effective in treating the manic phase of bipolar disorder. Educate to patient that
lithium can cause side effect such as gastrointestinal upset for the first 2 week, weight gain,
tremor and it has metallic taste. I will also monitor the serum lithium level after 5 days so that
it is between 0.8-1.2 mEq/L to prevent toxicity. I will also start him on atypical antipsychotic
as he had psychotic symptom. I will choose olanzapine because it has both antipsychotic and
mood stabilizing effect. I will also to prescribed patient with medium acting Benzodiazepine
such as Lorazepam for his sleep problem. I would avoid giving him Alprazolam because is
has short acting and rapid onset. This may cause patient to become dependence, intolerance
and addiction to it. After the symptoms stabilize for few months, I will slowly reduce
antipsychotics or stopped it, and maintained the mood stabilizer. I would also like to monitor
the lithium level for every 6 months. ECT may also consider if the acute mania was
unmanageable.

For psychosocial management, I would like to refer patient to psychologist to start with
Interpersonal Social Rhythm Therapy to addressing any interpersonal issues, improve his
sleep hygiene for example establish a strict bed time routine, limit any screen time use and
cut off any caffeine intake before going to sleep. This therapy also can help patient to manage
any stressful life event and improve patient resilience. Next, psychoeducation is very
important to this patient as well as to his family members. I would like to take non-
judgemental approach to educate them about the nature and the course of the disorder, the
necessity to get a prompt treatment, side effects of medications and also educate them to
recognise any early warning signs. I would also like to educate his family members to give
him fully social support and always monitor his progression of symptoms and avoid giving
patient any stress in the future. The relapse rate can be decrease when there is less expressed
emotion from family members. Based on CPG Management of Bipolar Disoder in adult,
cognitive behavioural therapy has shown to enhance symptomatic outcome and improve the
quality of life. Currently patient was unemployed and was fully support by his parents, hence
I would like to refer patient for financial help

Discussion
The possible predisposing factor for this patient is genetic as his uncle, aunty and cousin had
mental illness. Besides, this may be due to he was sexually abuse during his childhood.
Furthermore, her father also had Bipolar Disorder. The precipitating factor is changes of
sleep pattern recently and this may induce mania for the patient. The perpetuating factor is he
non adherent to his medications because he lost it and did not have any effort to get the new
one. I would like to obtain more information from patient if he had any negative attitude to
the drugs in general or he had any difficulty with the drug routine. This is very important to
be recognize to get a better clinical outcome. The protective factors for this patient is he able
to recognize the bipolar warning signs as he went to ED after experienced variety of
symptoms that may become worsen. Besides, currently he had no depressive symptoms and
suicidal thought.

The current problem is he had multiple admissions to hospital. Therefore, it is very crucial to
find out why he kept on having episodes. If he was not adherent to medication, then can
educate his family member to supervise and make sure that he is taking medication every
day. If he was compliance but the mood episode still occurs, may be can change the
medications or ECT can be done to him.

REFERENCES
1) Kaplan & Sadock’s Pocket Handbook of Clinical Psychiatry, 4th Edition
2) First Aid of Psychiatry Clerkship, 2nd Edition, 2005, McGraw Hill.
3) Desk Reference to the Diagnostic Criteria from DSM-V American Psychiatric
Association Arlington, VA