Video skill lab - ANAMNESIS DASAR | SKILL LAB #1

Summary

This video showcases a mock medical anamnesis where a student doctor interacts with a patient, Bapak Gilang, who complains of a headache. The student doctor performs a detailed assessment, exploring the patient’s lifestyle, work habits, and health history to determine the cause of the headache. After evaluating the symptoms, the doctor diagnoses the patient with tension-type headache (TTH), likely caused by lack of sleep and long hours in front of the computer. The patient is prescribed pain relief and advised to improve sleep habits and exercise regularly. Follow-up is recommended if symptoms persist.

Takeaways

• 😀 The patient is a 25-year-old male named Mr. Gilang who complains of a headache, primarily after waking up or staying up late.
• 😀 The headache is described as a pressure sensation across the whole head and is not alleviated by common pain relievers like Panadol.
• 😀 Mr. Gilang's headache started recently, and although it has been recurring, it has worsened from a mild pain to a more severe one (level 5 on a 10-point scale).
• 😀 The patient reports no associated symptoms such as nausea, vomiting, visual disturbances, or ear pain, indicating that the headache is isolated.
• 😀 Mr. Gilang has a sedentary lifestyle with long hours in front of a computer at work and irregular sleep due to job stress and late nights.
• 😀 He also has a smoking habit and does not engage in regular physical exercise, particularly during stressful work periods.
• 😀 The most likely diagnosis based on the anamnesis is **Tension-Type Headache (TTH)**, which is often triggered by stress, poor sleep, and prolonged computer use.
• 😀 The doctor prescribes pain relief medication (anti-nyeri) to alleviate the current headache symptoms.
• 😀 Lifestyle changes are recommended, including improving sleep hygiene and incorporating regular exercise to prevent future headaches.
• 😀 Mr. Gilang is advised to return for further evaluation if the symptoms persist or worsen in the next week, in case additional underlying conditions need to be ruled out.
• 😀 The doctor reassures the patient that the condition is likely due to stress and lifestyle factors, and emphasizes the importance of self-care and healthy habits to prevent recurrence.

Q & A

What is the main complaint that the patient, Gilang, presents with during the consultation?

Gilang presents with a complaint of a tension-type headache, characterized by a pressure-like sensation across his whole head.

How does Gilang describe the onset and nature of his headache?

Gilang describes the headache as starting after a late night of work and feeling like a pressure around his head. The pain becomes noticeable in the morning after waking up, especially following a night of staying up late.

What kind of medication did Gilang take to relieve the headache, and was it effective?

Gilang took Panadol, an over-the-counter pain reliever, but it was not effective in alleviating the pain.

What does the doctor suspect as the primary cause of Gilang's headache?

The doctor suspects the headache is caused by tension, likely due to lack of sleep and stress from work-related pressure.

What lifestyle factors does the doctor inquire about that may be contributing to the patient's headache?

The doctor asks about Gilang's sleep habits, work stress, smoking habits, and exercise routine. Gilang admits to insufficient sleep due to work and a lack of regular physical activity.

What is the doctor’s diagnosis based on the patient's symptoms and history?

The doctor diagnoses Gilang with a tension-type headache, which is typically caused by stress or sleep deprivation.

What advice does the doctor provide to Gilang for managing and preventing future headaches?

The doctor advises Gilang to get adequate sleep, reduce stress, and incorporate regular exercise into his routine to help prevent future headaches.

What treatment does the doctor prescribe to Gilang for his current headache?

The doctor prescribes an anti-pain medication to help relieve the current headache, advising Gilang to take it after meals.

What is the expected duration for recovery according to the doctor’s recommendation?

The doctor recommends that if Gilang’s symptoms do not improve within a week, he should return for further evaluation.

Are there any serious symptoms that would require more urgent medical attention in this case?

No serious symptoms, such as nausea, vomiting, visual disturbances, or ear issues, are reported. However, if symptoms persist or worsen, Gilang is advised to seek further medical attention.