Bed side teaching

Wednesday/ March 11th, 2015

General Anxiety Disorder

By

Preceptor

: Husnul Khotimah

P1555

Yestria Elfatma

R1556

: 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 PATIENT
0

Name
Sex
Age
Religion

: Mrs. Y
: Women
: 49 years old
: 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,
anxiety, easy to cry and get trouble for sleeping. Patient got medical
treatment 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 complaint
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)
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.
1

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
herself.
2. Medical disorder history
The patient didnt have some medical history disease, surgery
history, accident history, neurologic disorder, tumor, consciousness
disorder, 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.
d. Religion history
The patient is Moeslim. She believes to god but he dont 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
2

Explanation :

patient

: 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. Familys perception and hope
Family wanted the patient get well soon and continue her live.
H. Patients perception and hope
The patient wanted get well soon and continue her live.
III.
Internal Status
General Condition
Awareness
Blood pressure
Pulse

: Moderete ill
: Composmentis
: 120/80 mmHg
: 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
3

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
V.

Hand tremor
: present
Akatisia
: absent
Bradikinesia
: absent
Way of stepping : normal
Balance
: non disturbed
Rigiditas
: absent
Motoric
:
freely in any direction
555 555
Sensorik
: well propioseptif and exteroseptif
555
555
Refleks
: Phisiologic reflex (++/++), phatologic reflex (-/-)

Mental Status
Autoanamnesa
Pertanyaan
Jawaban
Siang bu. Ambo dokter Lai

Interpretasi
Compos mentis

muda Husnul dan iko

dokter muda Yesi. Buliah
kami tanyo tanyo subanta
buk?
Sia namo ibuk ?

Yurli

Dari ma ibuk ko?

Dima rumah ibuk?

Dari rumah
Piai, caliak se di status

Personal orientation
intact

ado ma

Oohh

iyo..Bara

umua 49 tahun

Good memory

ibuk kini?
Lai takana tahun bara Tahun 2015
kini buk?
Bulan apo kini buk?
Bulan maret
Kalau tanggal lai takana Tanggal 11

Time orientation not

disturbe

dek ibuk?
Manga ibuk kasiko?

Manambah ubek

Sakik ibuk?

Iyo nak ibuk cameh

cameh se taruih tp kini

lai kurang
Dek apo ibk cameh?
Ndak jaleh se do
Tu apo yang taraso dek Ibo se ati ko

Good discriminative
insight

tu

ibuk lai?
manangih se lai
Dek apo biasonyo ibuk Ndak lo jaleh dek apo
sadiah sampai manangih do
tu?
Tu

manga

manangih?

Apo

ibuk Ndak tau se, kadang

yang takana anak cameh tu

ibuk pikian?
manangih se lai
Emang manga anak ibuk Yo kadang anak alun
tu?

pulang

lai

kan

tu

cameh
Jam bara biasonyo anak Jam 9 alah pulang
ibuk talambek pulang?
mah
Tu apo yang ibuk Karajo, ibuk ndak lo
camehan?

Anak

karajo atau sekolah?

ibuk tau do, tiok anak ibuk

pai

sekolah

ibuk

manangih lo
Baa kok manangih ibuk Iyo cameh se ibuk kok
anak pai sekolah? Itu baa baa anak dilua,
sekali sekali se atau acok tiok hari, satiok anak
buk?

pai manangih ibuk,

cameh se mamikian
anak

tp

lai

ibuk
5

alihkan

kadang

karajo-karajo dirumah
(sambil

menghapus

airmata)
Tapi kan lai ndak ado Lai indak
apo-apo yang tajadi sm
anak ibuk kan?
Tu kalau anak lengkap Kalau

dirumah

dirumah lai ndak cameh- sadonyo lai indak, tp

cameh ibuk?

kalau tajago malammalam

Tu

menurut

ibuk

cameh

juo

ndak tau dek apo do

lai Indak tp ibuk ndak lo

wajar yang ibuk rasoan tau dek apo do, tp

tu?
Selain

ibuk
cameh

lai

taruih

Good discriminative
judgment

mancubo mengalihkan
jo Jantuang ko berdebar-

manangih apo yang ibuk debar

rasoan lai?
bilo biasonyo jantuang Kok tibo cameh tu
ibuk berdebar?
berdebar-debar
Kok indak cameh lai Lai ndak. Tp kini lai
ndak berdebar jantuang alah bakurang sejak
ibuk?
minum ubek
Alah sejak bilo ko ibuk Alah lamo ma
marasoan bantuak iko?
Sejak bilonyo lai takana Ndak takana do alah
ibuk?

ba lamo, tp patang
alah baranti barubek
dek

alah

lamak

rasonyo,

ubek

kok

paralu

dibali

se

sorang,

kini

alah

banyak lo taraso liak

6

Lalok ibuk baa?

Sejak

alah

minum

ubek kini alah lamak

lalok,

sabalunnyo

payah,

tajago-jago

malam
Ho berati alah lamak Lai makan bantuak
lalok

ibuk

yo,

kalau biaso juo

makan ibuk baa?

Ado
ndak

ibuk Indak

mandanga-danga suarosuaro?

Atau

Nampak

baying-bayangan?
Kok mancium baun- Indak juo do
baun?
Raso

ado

mamacikan

olfactory, visual, and

tactil halutination

yang Ndak

ibuk

ado

ndak?
Menurut ibuk, ibuk ado Ndak
maraso punyo kehebatan
dari yang lain ndak?
Ado ibuk maraso
kecek-kecekan

No acustic,

di Ndak
sm

urang?
Ibu, pernah maraso ndak Ndak

No Greatness
Delutional
No Suspicious
Delutional
Inferior feeling (-)

baguno?
Tu apo yang araso lai Alah itu se nyo
ibuk?
Berati yang taraso dek Iyoo
ibuk kini -acok camehcameh,

sadih

tu

manangih sorang se lai,

jantuang ibuk berdebardebar se lai kalau sedang
cameh tu kan? Makan
7

alah lamak lalok alah

lamak?
Ndak ado keluhan lain Indak
lai?
Aa iyo lah rajin-rajin Iyo
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.
Yo makasi yo buk alah Pulang lai
nio kami tanyo-tanyo,
kama ibuk siap ko lai?
Ha yo lah sekali lai Yo nak

samo-samo

makasi yo bu..hati-hati makasi yoo

ibuk pulang yo..
Based on the examination in March, 11th 2015
I. General Condition
Awareness

: Composmentis

Attention

: low

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
8

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
b.halutination

: absent
- acustic

: absent

- visual

: absent

- olfatorik

: absent

- 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
9

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
l. Others

: absent
:-

E. Instinctual impulse disorders

a. Abulia

: absent

b. Stupor

: absent

c. Raptus / impulsivitas

: absent

d. excitement state

: absent

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)

10

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

einfuhlung, 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
evaluated, discriminative judgment disturbed, intellectual deterioration

absent.
Sensation and perception disorder: illusion and hallucination absent.
Process of Thinking: slow, unclear and not sharp, circumstancial,
incoherrent, Sperrung, Hemmung, flight of ideas, verbigeration, central
pattern, phobia, delusion absent, suspicion absent, confabulation,
animosity and revenge, inferior feeling, less, guilty feeling, hypochondria

are aabsent.
Instinctual encouragement: abulia absent, stupor absent, raptus absent,
excitement state absent, sexual deviation absent, echophraxia absent,

vagabondage absent, pyromania absent, mannerisme absent.

Anxiety: no
Relation to reality: bad (behavior, feeling, thinking)

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
11

50-41: Symptoms serious, severe disability.

MULTIAXIAL DIAGNOSIS

F 33.3 Recurrent Depressive Disorder with Severe Episode with Psychotic

II
III
IV
V

Symptomps
No diagnosis
No diagnosis
Problem with primary support group (family), job, and economics
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 tab@ 0,5 mg

Amitriptyline 1 x tab @ 25 mg

B. Psychotherapy :
1.

Patient
Supportif psycotherapy
Psychoeducation

2. Family : Psychoeducation about

Patient disorder
Teraphy
PROGNOSIS

Onset
Relaps
Diagnosis

Assesment
Adult
Often
Recurrent
Depressive
Disorder

with

Good

Bad

Severe

Episode with Psychotic

Symptomps
12

Family Support
Medicine

Bad
Good

Respons
Marriage
Economy

Divorced
Moderete

to Dicipline

Condition
Obedience
take medicine
Trigger
Genetic
Penyakit

Overthinking about his

problem
Nothing
lain/ Nothing

gangguan lain

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
examination. Patients 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 doesnt has drunk history and using drug history. Physical examination
shows normal blood pressure of 120/80 mmHg. Cardiovascular, respiratory,
gastrointestinal, 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
happen to her child. She also felt tremor, palpitation and headache, so it can be
diagnose comphrehensive anxiety disorders.
13

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

everyday and thats 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 PPDGJIII. Patient is given Alprazolam 1 x tab @ 2 mg, Amitriptyline 1 x tab @ 25
mg.

14

SCHEME OF DISEASE HISTORY

2009
Anxiety,
palpitation,
headache, get
trouble to sleep,
and easy to cry,
everyday

2013
Getting better

2011
Her complaint
more decreased

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

2012
getting better

2010
The first time she
get thepary she felt
the symptoms
decreased

2014
Getting
better, and
she stop to
medical
check up