Case Report Sessions

Generalized Anxiety Disorder

BY:
Chaled Adams

P. 1265

Rahmat Saleh Eka Putra

RP. 1253

PRECEPTOR
dr. Yaslinda Yaunin, Sp.KJ

PSYCHIATRY DIVISION
MEDICAL FACULTY OF ANDALAS UNIVERSITY
RSUP DR. M.DJAMIL PADANG
2014

CASE REPORT

A female patient, aged 34 years old, admitted to the psychiatric clinic Prof.
HB.Saanin hospital Padang on December 17, 2014, with chief complaints:
patients often complain of experiencing dizziness and light headed. This
complaint is felt since 5 months ago.
Patient identity:
Name / Age

Mrs. EJ / 34 years old

MR

0168XX

Gender

Female

Marital status

Married

Religion

Muslim

Occupation / School

Housewife / High School

Citizen

Indonesian

Tribe

Minangkabau

Addres

Gg.Pusara RT XX / RW XX, Parak Laweh Pulai

Aie XX, Lubuk Begalung, Padang

A. Internal Status
General appearance

: Composmentis

Blood pressure

: 110/80 mmHg

Pulse

: palpable, regular, 82 times per minute,

Respiration

: toracoabdominal, regular, 20 times per minute

Temperature

: 36,60C

Respiratory system
Inspection

:
: Symmetrical on both left and right site in static and
dynamic state

Palpation

: Fremitus left side equal to the right side

Percussion

: Sonor throughout the lung fields

Auscultation

: Vesicular breath sounds, no ronkhi, and no wheezing

Cardiovascular system :
Inspection

: Ictus is not visible

Palpation

: Ictus was palpable 1 finger on the medial side of

LMCS RIC V

Percussion

: Cardiac border was obtained normal

Auscultation

: Pure heart sounds, regular rhythm, frequency 82x /

min, no cardiac murmur

Gastrointestinal system :
Inspection

: No Bulge

Palpation

: Liver and spleen were not palpable

Percussion

: Tympanic

Auscultation

: Normal intestinal murmurs

specific abnormalities

: not found

NEUROLOGICAL STATUS
I. Central nervous System

(sensory) :

sight, smell, hearing, taste, and touch

were fine
Symptoms of brain meningean stimulation : stiff neck negative
Symptoms of increase intracranial pressure : projectile vomitting negative,
progressive headache negative
Eyes
-

Movement

: can be moved in any direction, nistagmus negative

Perception

: diplopia negative

Pupil

: round, isochors,

Lights reflex

: positive / positive

Convergence reflex

: was not performed

Cornea reflex

: was not performed

Ophthalmology

II.

: was not performed

Motoric

Tone

: Eutone

Turgor

: good

Strength

: 555 555
555 555

Coordination

: Good

Reflex

Physiologic (patella) : ++/++

Pathologic

III.

: Babinsky reflex negative

Sensibility

: smooth and rough were

good
IV.

Vegetative neuron

: eating,

sleeping, and waking function were

normal
V.

Supreme functions

: Activity of

reading, languange, writing,drawing,and

numeracy can be performed well
VI.

Spesific disorder

stiffness

: none

tremor

: none

nasal stiffness

: none

occulogiric crisis

: none

torticolis

: none

Autoanamnesis

I.

Chief Complaints
Patients often complain of experiencing dizziness and light headed.
This complaint is felt since 5 months ago.

II.

Present History of illness

Patients often complain of experiencing dizziness and light headed.
This complaint is felt since 5 months ago.

Patients say the incident took place every day so that the patient
becomes confused to herself. The patient said that she as not enjoying
life in this world. Like having a very big sin and be always thinking of
her sins in the last few months. Patients think of deeds and sins in the
past with the death was coming. coupled with the state of the family
inheritance, which she felt very unfair distribution and incriminate
herself
The patient said that she did not have trouble sleeping excessive.
Only sometimes woke 1 or 2 times a week during the night, but then
fall back asleep. Patients say appetite is still good, and do good
routines such as bathing, praying.
The patient said that during her complaint progresses, the patient
was fully conscious. Never run amok, or speak for themselves. Patients
also said that she never saw the figure of a shadow passing in front of
her or hear their voices whisper around or there anything else from
outside to control the body.
In the past last year patient claimed to have never experienced any
trauma on any body part.
III. Past medical history

Patients say never experienced a severe disease associated body. Only a

common cold cough.
The patient said she had never had a history of hospitalization with any
indication.
The patient has control to the clinic with the same complaints
IV. Occupation History
Patient is a housewife.
V.

Marital Status
Married

VI. Socio-economic history

Patient was living with her husband. The house is a permanent one, there
is electricity, the source of water is from PDAM. Patient had a
motorcycle.
VII.

Family History

VIII. Graphic of illness

2014

tahun
2002

tahun
2004

tahun
2005

tahun
2009

tahun
2014

AUTOANAMNESIS
Pertanyaan

Jawaban

Assalamualaikum

Interpretasi

bu, Waalaikum salam, boleh Kesadaran baik

perkenalkan sayan dokter muda dok. Tapi tidak lama khan ? kooperatif
eka, dan ini dokter muda chaled, saya

mau

lgsg

kepasar

boleh kita berbicara sebentar ibu? soalnya?

Tidak lama kok bu. Maaf, Ini dok, kapalo awak ko Hipertim
sebelum,nya ibu datang kesini taraso agak oyong, acok Isi pikiran banyak
karena

apa?

Apa

yang

ibu paniang, agak sakik lo..

rasakan?

Oh gini ya Ni?
Eh?, uni orang minang asli?

Iya, uni lahir di padang Kooperatif

panjang, kalo orang minang
kan banyak pelajaran yang
bisa

diambil,

contohnya

alam takambang menjadi

guru
Ooh, tapi katanya uni kuliah Iya, dulu uni dibengkulu Orientasi waktu tidak
dibengkulu kan?

kuliah 2 tahun, tu masuk terganggu.

Orientasi

unand di padang ini tu tempat tidak terganggu

lanjut ke muhamadiah uni

Tu uni lah sarjana berarti?

juga pernah
Belum, uni nikah dulu trus
ndak lanjut kuliah, tu jadi

istri yang baik saja lagi.

Tu kok uni berobat disini?, emang Ndak tau, katanya uni Discriminatif
uni sakit? Sakit apa?

insight

banyak ngomong terus tu baik

dibawaknya

uni

berobat

kesini
Eh, tu udah berapa kali uni Dah,
dirawat?

beberapa

kali,

tu Orientasi personal baik

dokter uni yang sebenarnya

bukan pak yaunin, tapi ada
dokter uni dari padang

panjang.
Tu gak apa-apa berarti disini uni Iya, sekarang uni udah
biar sembuh dan tenang lagi

tenang kok, hehe?

Oiya tu lampu wc mati, ada

hantunya tu ndak ya?

Eh? Mang uni takut? Pernah Tidak sih, engak pernah tu, Halusinasi tidak ada
dengar suara-suara gitu? Ato itu buat yang penakut aja.
bayang-bayang?
Kalo cium bau-bau wangi ato Engak juga.
rasa-rasa dipegang ada
Oiya, uni kalo udah sehat dah Uni mau besarin anak uni, Abulia (-) waham (-)
boleh pulang mau ngapain lagi

baru lahir tapi ndak ada uni

susuin, trus uni jadi ibu

rumah tangga aja, hehe

Oiya, uni katanya pintar waktu Iya, uni bisa nyanyi, mau
disekolah kan?

lagu

apa?..

kemudian

pasien bernyanyi
Uni

juga

punya

teman

pena, di ingris sana, jadi

juga jago bikin surat. Mau
lihat, sini pijam kertas dan

pena.
Pasien menulis surat dan

Oiya, ini uni, coba saya mau lihat

Kalo gambar bisa?

menggambar.
Ooh, ya lah, makasih ya uni, Iya, hehehe...
hebat-hebat.

SUMMARY OF PSYCHIATRYCH TEST

I. General Appearance
Conciousness/ sensorial : composmentis / good
Manner

: cooperative

Motoric

: active

Facial expression

: fair

Verbalization

: can speak fluently

Psychic contact

: could be done, appropriate, and long

Attention

: present

Initiative

: less

II. Specific condition

A. Affective
1.

Affective condition

2.

Emotional

: appropriate
:

a. Stability

: labil

b. Control

: fair

c. Echt/Unecht

: Echt

d. Einfuhlung

: adequate

e. Deep/shallow

: deep

f. Differentiation scale

: wide

g. Emotional flow

: fast

B. Intelectual function and condition

a. Memorization ability

: good

b. Concentration

: good

c. Orientation

: not disturbed

d. knowledge

: good

e. Discriminative insight

: not disturbed

f. Intelligence prediction

: average

g. Discriminative judgement

: not disturbed

h. Intelectual decreasing

: none

C. Sensation and perception abnormalities

a. illusion

: none

b. hallucination
- accoustic

: none

- visual

: none

- olfatoric

: none

- tactile

: none

D. Thought process condition

Speed of thought process

: fair

quality of thought :
1. clear and sharp

: clear and sharp

2. incoherent

: none

3. Sperrung

: none

4. Hemmung

: none

5. Flight of ideas

: none

6. verbigeration

: none

7. preservation

: none

Thought condition
1. Central pattern

: none

2. phobia

: none

3. obsession

: none

4. delusion

: none

5. suspicion

: none

6. confabulation

: none

7. repulsion

: none

8. inferior feeling

: none

9. Much/little

: little

10. feeling guilty

: present

11. feeling fear

: present, fear of death

12. hypochondria

: none

13. others

: none

E. Instingtual drive and behaviour abnormalities

F.

1. abulia

: none

2. stupor

: none

3. raptus/impulsivity

: none

4. excitement state

: none

5. sexual deviation

: none

6. echopraxia

: none

7. vagabondage

: none

8. pyromani

: none

9. mannerism

: none

10. others

: none

Overt anxiety

G. Reality testing ability

: present
: not disturb in behavior and feeling

MULTIPLE AXIS RESUME

Axis 1. Clinical Syndrome
Patients often complain of experiencing dizziness and light headed. This

complaint is felt since 5 months ago.

General appearance: composmentis cooperative, sensorial is fine, Attention is
good, initiative is good, motoric active, facial expression is fair, verbalization
fluent, psychic contact could be done, appropriate, long

Specific condition
1. Affective condition : fair, labil, little, echt, adequate, deep, wide, fast.
2. Intelectual condition and function: memorization ability good, no
difficulty in concentrating, orientation is not disturbed, knowledge is good,
discriminative insight not disturbed, intelligence prediction is average,
discriminative judgement is not disturbed.
3. Sensation and perception abnormalities: no illusion, acoustic, olphactoric,
visual and tactile hallucinations are none
4. Thought process condition : fair, coherent, and rich.
5. Reality testing ability : not disturbed in behavior and feeling
6. Overt anxiety : present
Axis II. Personality Disorder and mental retardation disorder
Personality

: none

Mental retardation

: none

Axis III. General medical condition

None
Axis IV. Phsycosocial and environtment stressor
- Stress in primary support group and economy
Axis V. Global assesment of function
-

Social relationship ( visiting a friend, attending a wedding party, praying

at mosque, and other civillian activity) could be implemented

free time activity (watching TV, reading, recreation) could be done well
partially. Mostly spend her time at home.

Daily activity (bathing, washing, working) could be implemented.

Multiple Axis Diagnose

I.

F.41.1 General Anxiety Disorder

II.

No Diagnose

III.

No Diagnose

IV.

No Diagnose

V.

GAF 90-81

Differential Diagnose
F.41.2 Anxiety Disorder Mixed type with Depression

Therapy
Clobazam 2X1 tab @ 5 mg
Merlopam 1X1 tablet @ 0.5 mg
PROGNOSE
Onset
Relaps
Diagnose

Penilaian
adult
Exist
F41. 1 Gangguan

Family support
Medical Response
State of Economy
Medication adherence
Precipitating factors
Family History
Other Disease / Other

Cemas Menyeluruh
Present
Good
average
obedient
Clear
Abstance
Abstence

Disorder
Clinical

: dubia et bonam

Functional

: dubia et bonam

Social

: dubia et bonam

Good

Bad