FACULTY OF MEDICINE AND HEALTH SCIENCES

SESSION 2011/2012

CASE WRITE-UP
MENTAL HEALTH POSTING
YEAR 5

BIPOLAR MOOD DISORDER IN MANIC PHASE

ABDUL QAYYUM BIN JUMIDEY

1071223
PATIENT’S DATA
Name : Q
Age : 23 years old
Sex : Male
Date of Admission : 28 December 2011
Date of Clerking : 5 January 2012
Source of Info : Patient, Bed head ticket

CHIEF COMPLAINT
Patient was brought in by police to Hospital Kuala Lumpur Emergency
department due to aggressive and disruptive behaviour on the day of admission.

HISTORY OF PRESENTING ILLNESS

Four days prior to admission, the patient started to react abnormally since last
as he started to become talkative, talking irreverently and easily irritable. He also
noted to have many plans and ideas to do such as buying clothes for his mother,
taking photograph with his family, and plan to do kenduri arwah for his father
although his family never plan about it. Patient said he did not go for work and
sometimes he feel guilt although he did not do anything wrong. However, there is no
physical aggression at that time.
Patient then gave a phone call to his family in Segamat and told them that he
started to feel unwell. Later then, his closest family in Kuala Lumpur brought her to
the emergency clinic two days before admission. But then he was asked to come back
on his next appointment to psychiatric clinic on 28 December 2011(day of admission)
Apparently his condition worsens and he becomes more irritable. On the day
of admission, patient was being aggressive and disruptive by breaking the house grill
and punched the glass window. His housemate then had lodge a police report about
the incident and the police manage to bring him to the hospital.
Upon further questioning, he admitted that he was not compliant to his
medication, had sleep disturbance, easily irritated, talkative and had many plan to do.
However, he denied of feeling depressed or elevated mood, grandiousity idea, having
suicidal ideation, neither hallucination nor delusion.
Patient was disturbing in the ward during few days after admission and tries to
provoke the staff to have a fight with him.
PAST PSYCHIATRIC HISTORY
Back in 2007, he was diagnosed with Major Depression with psychotic
features at Hospital Mesra, Bukit Padang when he was trained as policeman. The
detected stressors are the rough, high discipline and strict training plus the patient
condition that was far from his family for the first time. He was on tab. Supiride
100mg on that time
After completed his training in February 2008, he was posted to Dang Wangi
police station. He was referred from Hospital Mesra to Hospital Kuala Lumpur to
continue his follow-up and treatment. The medication then was changed to tab.
Perphenazine 4MG and subsequently tab. Epilim 200mg was added. He came for
follow up as scheduled.
The first admission to the ward was on November 2008 due to aggressive
behaviour. He was then discharged with tab. Epilim 200mg, tab. Supiride 200mg and
OM/ 400mg ON, tab Artane 2mg. He came for follow up according to schedule and
noted compliant to treatment.
Subsequent admission was on May 2010 where he was prescribed with tab
Lithium, tab artane and chlorpromazine and on the next admission in June 2010 he
started electroconvulsive therapy (ECT) for 8 times with continuation of maintenance
ECT after discharge. He is maintaining well till 3 months before current admission,
when he suppose to have maintenance ECT but the ECT machine was broke. Instead
of recieving ECT, he was given the same medication and new appointment in 3
month.
.
PAST MEDICAL & SURGICAL HISTORY
No other previous medical or surgical history

FAMILY HISTORY

60, deceased 52, cleaner

26, army 23, patient 20, student 18, student

 His father died in 2009 at the age of 60. But patient not really sure of the
diagnosis but said his father was unwell before he died. His late father used to work as
rubber taper and he described their relationship is good and close.
His mother is living well and work as cleaner in Segamat. He describes her
mother as caring soft and nice person. He also closes to her and always contacts her.
He is 3rd in his siblibgs. His eldest brother is 26 years old, work as an army in
Kluang. He has a younger brother aged 20 years old and a younger sister aged 18
years old. Bot of them are still studying in Johore. Patient describe that their
relationship are close and he denied any problem in the family.
Beside, there is no familial history of mental illness in the family.

PERSONAL HISTORY
Birth & childhood history
He was born full term via spontaneous vaginal delivery with normal
developmental milestones. He could not recall any problem during his childhood or
any childhood neurotic traits such as school refusal, thumb sucking or bed wetting.
Education history
He received his primary and secondary education in Segamat. He said he was
an average student. Later he joined training for Sijil Kemahiran Malaysia in electrical
and he completed it. Subsequently, he had been offered to be a police and was sent to
Sabah for training and complete the training successfully.
Employment history
Currently he is working as policeman at Dang Wangi Police Station since
2008. He is in charge in the administrative section. Previously he was in charge in the
record section and the firearms store. However, he claimed that he never use firearm
while working at the station. He is able to socialize well with his working mate. They
seem to understand about his condition. His income is ranging from RM 1200 – RM
1500 per month.
Sexual & Marital history
He is single and he said he has a girlfriend before. He denied any recent
relationship with women.
Social history
He is staying at Kg. Baru by renting a room with a couple of friend. All his
family are staying in Johore
Habit & substance abuse
He is an active smoker since age of 13 years old. Normaly he smokes 20 stcks
per day. He claimed that he never involved with alcohol and drugs.

PREMORBID PERSONALITY
Patient describes himself as good brother, friend and son. He admitted he also
short tempered person especially with his friend that always borrow his money but not
paying him back.

MENTAL STATE EXAMINATION

General appearance
Mr Q is a young Malay man with normal built; he dressed neatly in hospital
attire. His personal hygiene was fair. He was alert, conscious and comfortable. He
was forthcoming when called for interview, but easily distractible during the
interview. He was cooperative and has good rapport and eye contact and did not
display any mannerism or abnormal movement or tremors.
Speech
Patient spoke in Malay. His speech was coherent and relevant. He is talkative
and sometimes raised in tone. There was no pressure of speech or flight of ideas.
Mood & affect
His mood was elated but not irritable (scale: 8 out of 10). His affect was
appropriate. His affect was congruent to his thought with normal intensity.
Thought & perception
He has normal stream and form of thought. He has no delusion or
hallucination
Cognitive function
He is fully oriented with time and place. Cognition cannot formally tested
since he is easily distracted.
Insight
He has partially good insight. He is aware of being ill, recognized the
abnormality of the phenomena is due to mental illness and felt that he needed to be
treated but he said he prefer ECT rather than taking medication.

PHYSICAL EXAMINATION
General Examination:
The vital signs are as below:
Blood pressure : 120/70 mmHg
Pulse rate : 100 beats/min, regular rhythm, good volume
Respiratory rate : 18 cycles/min
Temperature : 37.0 °C

He was alert. The hydration was fair. No signs of jaundice, anaemia, cyanosis,
clubbing and pitting oedema noted.

Cardiovascular System:
Apex beat is not displaced, no parasternal heive or thrill, dual rhythm heard with no
murmur. 
Respiratory System:
The trachea was not deviated. Confine to both anterior and posterior side: air entry
equal bilaterally; vesicular breath sounds heard without added sounds.
Abdomen:
Soft and non tender on palpation. No organomegally, normal bowel sound heard
Musculoskeletal:
Able to move all limbs
Central nervous system:
Tone normal bilaterally with 5/5 power

INVESTIGATIONS
1. Blood Investigation
 Full blood count: Normal
  Renal profile: Normal
 Thyroid function test:
2. Urine Investigation
 Dipstick for drugs: negative to all
3. Electrocardiogram
 Normal sinus rhythm

FORMULATION
Problems Synopsis
1. 23 years old Malay gentleman with episode of aggressive and disruptive
behaviour had been talkative, talking irreverently, easily irritable and having
disturbance in sleep and flight of ideas for almost a week
2. Previously diagnosed with major depression with psychotic features
3. Four episodes of admission to the wards with same chief complaint
4. Incompliance to medication
5. Less of family support due to logistic distance.
6. Risk of having side effect of medicine.
7. Danger if patient handling firearms.

Differential diagnosis
1. Bipolar Mood disorder in manic phase with psychotic features
2. Schizophrenia
3. Psychotic depression

AETIOLOGY
1. Precipitating factors
 Incompliance to medication
 Less of family support due to logistic distance.
2. Predisposing factors
 History of mental illness
 Bad tampered patient
 3. Perpetuating factors
 Incompliance to medication

BIOPSYCHOSOCIAL & SPIRITUAL MANAGEMENT PLAN

1. Continue the maintenance ECT
2. Continue the current medication
3. For his sleeping problem, short-acting Benzodiazepine such as tablet can be
used to help induce sleep
4. Monitor the extra pyramidal side effect and dependence towards
benzodiazepine
5. Support patient and educate the family on the disease
6. Advice about lifestyle i.e avoidance of triggers for relapse such as sleep
deprivation
7. Endorse a referral letter to his supervisor about advice on him dealing with
firearm.
8. Advised to perform his responsibilities as a Muslim. He can do zikir or recite
the Holy Quran to calm his temper.

PROGNOSIS
Overall, the average length of a manic episode is about four months. After a
first manic episode, about 90% of patients will experience further manic and
depression symptoms, and ythe inter-episode interval tends to become progressively
shorter. The prognosis is therefore quite poor, but is more so in rapid-cycling, and less
so in bipolar II. About 10% go on to commit suicide but rate of attempted suicide is
much higher.