Bed side teaching

Wednesday/ March 11th, 2015

General Anxiety Disorder

By : Husnul Khotimah P1555

Yestria Elfatma R1556

Preceptor : dr. Yaslinda Yaunin, Sp.KJ

DEPARTMENT OF PSYCHIATRY

MEDICAL FACULTY OF ANDALAS UNIVERSITY

GENERAL HOSPITAL OF M.DJAMIL – PSYCHIATRI HOSPITAL

HB SAANIN

PADANG

2015

I. IDENTITY OF PATIENT0

Name : Mrs. Y

Sex : Women

Age : 49 years old

Religion : Moslem

Ethnic : Minangkabau

Last education : Graduated of Junior high school

Job : Housewife

Marriage : Married

Address : Piai Atas no.5 Padang

Patient entered the hospital on March 11th, 2015, accompanied by

herself.

II. HISTORY OF PSYCHIATRY

Data was get by :

Autoanamnesis on March 11th, 2015.

A. Chief Complaint

The patient came to hospital for a monthly routine check up.

B. Recent History

In March 2015,

Patient come to hospital because she felt a headache, palpitations, anxi-

ety, easy to cry and get trouble for sleeping. Patient got medical treat-

ment in polyclinics M. Djamil Hospital.

C. Previous History

1. Psychiatry disorder history

In 2007 (patient forgot the month and the date of the onset)

Patient complaint anxiety, palpitations, and headache. This com-

plaint has been triggered when she remember her child, but she still

can controlled it and she still do activities as usual.

In 2009 (patien forgot the month and the date of the onset)1

Patient always felt a headache, palpitations, and often felt anxiety.

The patient also felt sad, lack to sleep and easy to cry when anxious.

It was triggered when their children were not home.

Patient got medical treatment in polyclinics M Djamil Hospital and

routin control until Juli 2014

In may 2014, patient not came again to hospital, she felt she was

good. When her symptoms was return, she bought the drug with her-

self.

2. Medical disorder history

The patient didn’t have some medical history disease, surgery his-

tory, accident history, neurologic disorder, tumor, consciousness dis-

order, HIV.

D. Private History

1. Prenatal/ Perinatal period

Patient was born as the 1st child of 5 siblings. Patient was born on

time and norm weight. The pregnancy was helped by indigenous

medical practitioner and cried.

2. Early pediatric period (0-3 years)

Patient grew and developed healthy like others.

3. Middle pediatric period (3-11 years)

Patient grew and developed healthy like others, had friends.

4. Late pediatric period and adolescence period

Patient grew and developed healthy like others, had friends.

5. Adult period

a. Education history

The patient got education until junior high school.

b. Job history

She is a housewife

c. Marriage history

Married one time since 25 years ago.2

d. Religion history

The patient is Moeslim. She believes to god but he don’t prays

5 times a day.

e. Psychosexual history

There is no history of psychosexual history.

f. Social activity

The patient and neighbor had no conflict.

g. Violation of law history

There is no history of violation of law.

E. Family History

Explanation : : Man

: Woman

: Patient

: living with patient

F. Recent life situation

The patient lives with her husband and their children at permanent

house. Their communication is good. Electricity (+), TV (+), drinking

water from PDAM.

G. Family’s perception and hope

Family wanted the patient get well soon and continue her live.

H. Patient’s perception and hope

The patient wanted get well soon and continue her live.

III. Internal Status3

patient

General Condition : Moderete ill

Awareness : Composmentis

Blood pressure : 120/80 mmHg

Pulse : Regular, strong lift, frequency 83

times/minute

Respiration :Moderate, torachoabdominal, frequency 21

times/minute

Temperature : Afebril

Height : 153 cm

Weight : 49 kg

Nutritional status : well

Cardiovascular system :

Inspection : Ictus cordis not visible

Palpation : Ictus palpable around one finger medial to left

midclavicular line, 5th intercostal space

Percussion : Up: 2nd intercostal space, left: one finger medial to

left midclavicular line, right: dextra sternalis line

Auscultation: normal and regular heart sound, murmurs absent

Respiratoric System

Inspection : Simetric statically and dinamically

Palpation : Fremitus similar between left and right chest

Percusion : Sonor all over the thorax

Auscultation : Vesicular breath sound present, ronchi absent,

wheezing absent

Specific abnormalities: -

IV. Neurologic Status

GCS : E4M6V5

Meningeal Sign : absent

Extrapiramidal sign

- Hand tremor : present4

- Akatisia : absent

- Bradikinesia : absent

- Way of stepping : normal

- Balance : non disturbed

- Rigiditas : absent

- Motoric : freely in any direction

- Sensorik : well propioseptif and exteroseptif

- Refleks : Phisiologic reflex (++/++), phatologic reflex (-/-)

V. Mental Status

Autoanamnesa

Pertanyaan Jawaban Interpretasi

Siang bu. Ambo dokter

muda Husnul dan iko

dokter muda Yesi. Buliah

kami tanyo tanyo subanta

buk?

Lai Compos mentis

Sia namo ibuk ? Yurli Personal orientation

intact

Dari ma ibuk ko? Dari rumah

Dima rumah ibuk? Piai, caliak se di status

ado ma

Oohh iyo..Bara umua ibuk

kini?

49 tahunGood memory

Lai takana tahun bara kini

buk?

Tahun 2015

Time orientation not

disturbeBulan apo kini buk? Bulan maret

Kalau tanggal lai takana

dek ibuk?

Tanggal 11

Manga ibuk kasiko? Manambah ubek Good discriminative

insight

Sakik ibuk? Iyo nak ibuk cameh

cameh se taruih tp kini

5

555 555 555 555

lai kurang

Dek apo ibk cameh? Ndak jaleh se do

Tu apo yang taraso dek

ibuk lai?

Ibo se ati ko tu

manangih se lai

Dek apo biasonyo ibuk

sadiah sampai manangih

tu?

Ndak lo jaleh dek apo

do

Tu manga ibuk manangih?

Apo yang ibuk pikian?

Ndak tau se, kadang

takana anak cameh tu

manangih se lai

Emang manga anak ibuk

tu?

Yo kadang anak alun

pulang lai kan tu cameh

Jam bara biasonyo anak

ibuk talambek pulang?

Jam 9 alah pulang mah

Tu apo yang ibuk

camehan? Anak ibuk karajo

atau sekolah?

Karajo, ibuk ndak lo tau

do, tiok anak ibuk pai

sekolah ibuk manangih

lo

Baa kok manangih ibuk

anak pai sekolah? Itu sekali

sekali se atau acok buk?

Iyo cameh se ibuk kok

baa baa anak dilua, tiok

hari, satiok anak pai

manangih ibuk, cameh

se mamikian anak tp lai

ibuk alihkan kadang

karajo-karajo dirumah

(sambil menghapus

airmata)

Tapi kan lai ndak ado apo-

apo yang tajadi sm anak

ibuk kan?

Lai indak

Tu kalau anak lengkap

dirumah lai ndak cameh-

cameh ibuk?

Kalau dirumah sadonyo

lai indak, tp kalau tajago

malam-malam cameh

juo ndak tau dek apo do

6

Tu menurut ibuk lai wajar

yang ibuk rasoan tu?

Indak tp ibuk ndak lo

tau dek apo do, tp ibuk

lai taruih mancubo

mengalihkan

Good discriminative

judgment

Selain cameh jo manangih

apo yang ibuk rasoan lai?

Jantuang ko berdebar-

debar

bilo biasonyo jantuang ibuk

berdebar?

Kok tibo cameh tu

berdebar-debar

Kok indak cameh lai ndak

berdebar jantuang ibuk?

Lai ndak. Tp kini lai

alah bakurang sejak

minum ubek

Alah sejak bilo ko ibuk

marasoan bantuak iko?

Alah lamo ma

Sejak bilonyo lai takana

ibuk?

Ndak takana do alah ba

lamo, tp patang alah

baranti barubek dek alah

lamak rasonyo, ubek

kok paralu dibali se

sorang, kini alah banyak

lo taraso liak

Lalok ibuk baa? Sejak alah minum ubek

kini alah lamak lalok,

sabalunnyo payah,

tajago-jago malam

Ho berati alah lamak lalok

ibuk yo, kalau makan ibuk

baa?

Lai makan bantuak

biaso juo

Ado ndak ibuk mandanga-

danga suaro-suaro? Atau

Nampak baying-bayangan?

Indak

No acustic, olfactory,

visual, and tactil

halutination Kok mancium baun-baun? Indak juo do

Raso ado yang mamacikan

ibuk ado ndak?

Ndak

Menurut ibuk, ibuk ado Ndak No Greatness

7

maraso punyo kehebatan

dari yang lain ndak?Delutional

Ado ibuk maraso di kecek-

kecekan sm urang?

Ndak No Suspicious

Delutional

Ibu, pernah maraso ndak

baguno?

Ndak Inferior feeling (-)

Tu apo yang araso lai ibuk? Alah itu se nyo

Berati yang taraso dek ibuk

kini -acok cameh-cameh,

sadih tu manangih sorang

se lai, jantuang ibuk

berdebar-debar se lai kalau

sedang cameh tu kan?

Makan alah lamak lalok

alah lamak?

Iyoo

Ndak ado keluhan lain lai? Indak

Aa iyo lah rajin-rajin ibuk

kontrol yo tu tanang-tanang

se pikiran tu buliah ndak

cameh ibuk, kan anak ibuk

lai elok-elok se. buliah ibuk

bisa tanang bisa lalok ndak

pakai ubek lai yo.

Iyo

Yo makasi yo buk alah nio

kami tanyo-tanyo, kama

ibuk siap ko lai?

Pulang lai

Ha yo lah sekali lai makasi

yo bu..hati-hati ibuk pulang

yo..

Yo nak samo-samo

makasi yoo

Based on the examination in March, 11th 2015

I. General Condition

Awareness : Composmentis Attention : low

8

Attitude : Cooperative Inisiative : bad

Motoric behaviour : hypoactive

Facial expression : poor

Speech and verbal : speak fluently and clear

Physical contact : could be done, not natural, and short time

II. Spesific condition

A. Natural State of Feeling

1. Afective condition : hipothym

2. Emotion Living : a. Stability : labil

b. Control : controlled

c. ech – unecht : echt

d. einfuhlung ( invoelaarhaid ) : inadequate

e. deep-shallow : shallow

f. differentiation scale : narrow

g. emotion flow : slow

B. Intelectual Funnction

a. Memory (amnesia) : not good

b. Concentration : not good

c. Orientation

( time, spatial, personal, situation) : disturbed

d. general knowledge : difficult to evaluate

e. discriminative insight : disturbed

f. alleged level of intelegency : cannot evaluated

g. discriminative judgment : disturbed

h. intelectual deterioration : absent

C.Perseption and sensation anomaly

a. illution : absent

b.halutination - acustic : absent

- visual : absent

- olfatorik : absent9

- tactil : absent

D. Way of Thinking

1. Psikomobilitas : slow

2. Thingking process

a. clear and sharp : unclear and not sharp

b. Sirkumstansial : absent

a. Inkoherrent : absent

b. Sperrung : absent

c. Hemmung : absent

d. Flight of ideas : absent

e. Verbigerasi Persevarative ( Persevaratich ) : absent

3. Contents

a. Central pattern : absent

b. Phobia : absent

c. Obsess : absent

d. Dellusion : absent

e. Suspicion : absent

f. Confabulation : absent

g. Animosity/revenge : absent

h. Inferior feeling : absent

i. Much/less : less

j. Guilty feeling : absent

k. Hippochondria : absent

l. Others : -

E. Instinctual impulse disorders

a. Abulia : absent

b. Stupor : absent

c. Raptus / impulsivitas : absent

d. excitement state : absent10

e. sexual deviation : absent

f. Echophraxia : absent

g. Vagabondage : absent

h. Piromani : absent

i. Mannerisme : absent

j. Others : -

F. Overt anxiety : no

G. Relation to reality : bad (behavior, feeling, thinking)

VI. Multiaxial Evaluation

Axis I. Clinical Syndrome

Anamnesis

General condition: cooperative, hypoactive, poor, speaking fluently and clear,

psychic contact could be done for short duration of time, attention low.

Specific condition

Natural state of feeling : hypothym, labil, controlled, echt, inadequate ein-

fuhlung, shallow, narrow differentiation scale, slow emotion flow.

Intellectual condition : memorizing abililty not good, concentrarion ability

not good, orientation disturbed, general knowledge difficult to evaluate,

discriminative insight disturbed, allegged level of intelegency cannot eval-

uated, discriminative judgment disturbed, intellectual deterioration absent.

Sensation and perception disorder: illusion and hallucination absent.

Process of Thinking: slow, unclear and not sharp, circumstancial, incoher-

rent, Sperrung, Hemmung, flight of ideas, verbigeration, central pattern,

phobia, delusion absent, suspicion absent, confabulation, animosity and re-

venge, inferior feeling, less, guilty feeling, hypochondria are aabsent.

Instinctual encouragement: abulia absent, stupor absent, raptus absent, ex-

citement state absent, sexual deviation absent, echophraxia absent,

vagabondage absent, pyromania absent, mannerisme absent.

Anxiety: no

Relation to reality: bad (behavior, feeling, thinking)11

Axis II. Personality disorder and mental retardation

There is no personality disorder and mental retardation

Axis III. General Medical Condition

No history of head trauma, malaria, typhoid, and other disease which

needs hospitalization. No history of alcohol and drugs consumption.

Axis IV. Psychosocial and environment

Problem with primary support group (family), job, and economics

Axis V. Global Assessment of Functioning

50-41: Symptoms serious, severe disability.

MULTIAXIAL DIAGNOSIS

I. F 33.3 Recurrent Depressive Disorder with Severe Episode with Psychotic

Symptomps

II. No diagnosis

III. No diagnosis

IV. Problem with primary support group (family), job, and economics

V. GAF 50-41

DIFFERENTIAL DIAGNOSIS

1. F33.8 Another Recurrent Depressive Disorder

2. F33.9 Recurrent Depressive Disorder Unspecified

3. F25.1 Depressive Type of Schyzoafektive Disorder

THERAPY

A. Pharmacotherapy :

Alprazolam 1 x ½ tab@ 0,5 mg

12

Amitriptyline 1 x ½ tab @ 25 mg

B. Psychotherapy :

1. Patient

Supportif psycotherapy

Psychoeducation

2. Family : Psychoeducation about

Patient disorder

Teraphy

PROGNOSIS

Assesment Good Bad

Onset Adult √

Relaps Often √

Diagnosis Recurrent Depressive

Disorder with Severe

Episode with Psychotic

Symptomps

√

Family Support Bad √

Medicine Respons Good √

Marriage Divorced √

Economy

Condition

Moderete √

Obedience to take

medicine

Dicipline √

Trigger Overthinking about his

problem

√

Genetic Nothing √

Penyakit lain/

gangguan lain

Nothing √

13

Quo ad vitam : bonam

Quo ad fungsionam : bonam

Quo ad sanationam : dubia ad bonam

The thing that can make good prognosis : onset, medicine respons, economy

condition, obedience to take medicine, genetic, and no other disease and disorder.

The thing that can increase bad prognosis : relaps, diagnosis, family support,

divorced, and the trigger.

XII. CASE ANALYSES

The diagnosys of the patient got from medical history and physical examina-

tion. Patient’s chief complains anxiety that happen everyday in more than six

month. She also felt palpitation, headache, get a trouble for sleep and easy to cry.

She doesn’t has drunk history and using drug history. Physical examination shows

normal blood pressure of 120/80 mmHg. Cardiovascular, respiratory, gastroin-

testinal, and neurologic examination shows no abnormalities.

According to PPDGJ III, if anxiety symptoms showed everyday for several

weeks until month and its free floating. Patients felt something bad luck was hap-

pen to her child. She also felt tremor, palpitation and headache, so it can be diag-

nose comphrehensive anxiety disorders.

According to DSM IV, if anxiety symptomps showed during a day and ev-

eryday and that’s happen more 6 month, the patient difficult to controlled her

anxiety and anxiety can be meaningful to make clinical disorder it can diagnose

General anxiety disorder.,

Psychic contact could be done, natural, persist for long duration, hypothym,

labile, good controlling, echt, deep, narrow differentiation scale, fast emotion

flow, Intellectual deterioration is absent. Discriminative insight and discriminative

judgment is good, Sperrung, Hemmung is absent.

Patient is diagnosed with General Anxiety Disorder as stated in the PPDGJ-

III. Patient is given Alprazolam 1 x ½ tab @ 2 mg, Amitriptyline 1 x ½ tab @ 25

mg.

14

SCHEME OF DISEASE HISTORY

0

2009Anxiety,

palpitation, headache, get

trouble to sleep, and easy to cry,

everyday

2010The first time she

get thepary she felt the symptoms

decreased

2015Her complaint was return and she go to polyclinic M. Djamil

Padang

2014Getting

better, and she stop to

medical check up

2011Her complaint more decreased

2013Getting better

2012getting better