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GENERAL ANXIETY

DISORDER
Novia Purnama Sari P 1650
Septia Endike P 1652
I. IDENTITY OF PATIENT
Name : tn. YEP
Gender : male
Age : 37 tahun
Marital status : divorced
Address : Kp Ganting, Kecaamatan Lengayang
Kabupaten Pesisir Selatan
Occupation and school: Civil Servant
Religion : Islam
Citizen : Indonesian
Race : Minangkabau
II. HISTORY OF PSYCHIATRY
Data was get by :
Autoanamnesis on August , 20th 2015
Alloanamnesis on August, 26th 2015

Chief Complaint
The patient was noisy, restless since 7 days a go
RECENT HISTORY
In July 2015,
Noisy and restless since these 7 days.
Irritability, damaging household appliance.
Lack of sleep, lazy to take bath and eat.
When he was going to work by motorcycle, he stopped
before reach the hospital, left his motorcycle and then
hang around randomly by foot. And then his family picked
him up.
Sometimes he did not recognize his brother, he thought
his brother was another person and angried him.
He often listen to a rumbling sound from his mind that
controlled him and saw a huge creature. This condition
appeared since his ex wife take a way their only son and
married to another man.
He was hospitalized at 8 month a go at RSJ Prof Hb
Saanin for about 20 days and discharged in stable
condition. He routinly controlled to the hospital but he did
not drink the medicine.
PAST HISTORY
Psychiatry disorder history

Year 2007
Patient was firstly experience the mental illness in 2007.
He was irritabilited, rumping at his office room, damaging
computer and working stuff. He treathening other with
stones. Then he was hospitalized for the first time for
about 2 weeks. After that he did not do routine check up
but he can doing activity like normal person.
CONTINUE
Year 2011-2014
At 2011, he became irritabilited again, damaging
household appliance, talking and laughing alone. He was
hospitalized for about 6 times with the same complains.
He did routine checked up and took the medicine
routinely.
MEDICAL DISORDER HISTORY
The patient didnt have some medical history disease,
surgery history, accident history, neurologic disorder,
tumor, consciousness disorder, HIV.
PRIVATE HISTORY
Infant : born spontaneously, birth was assisted
by dukun beranak, no history of jaundice,
cyanosis or seizure.
Childhood : growth and development suitable for
his age. His parents always give what their son
want.
Adolescence : patient have some friend and like
doing social things.
Educational Background
Elementary school Senior high school : patient was a
clever student. He graduated excelently and got an
invitation to continue his study at IPB Bogor.
D3 : He finished his study at 3 years.

Work history
He work in a hospital at Kambang as a laboratory staff, as
a civil servant.
Marital status
Patient got married at 2009

having a son that he loved so much

He got divorced at the early 2015

He lived with his only son. His daily needs (e.g. cooking
and another house work) was helped by his cousin who
living in his neighbourhood. Sometimes his ex wife take
their son for a several times

His ex wifetake their son and did not returned back and
then she married to another man
Socio economic status
Patient lived alone in a permanent house (his own house),
there is electricity
Income source from his self
He can pay all he needed.
Family History

There is no family member who have mental illness


INTERNAL STATUS
NEUROLOGIC STATUS
Mental Status
Pertanyaan Jawaban Interpretasi
GENERAL CONDITION
SPESIFIC CONDITION
MULTIAXIAL EVALUATION
Axis I. Clinical Syndrome
Anamnesis :
General condition:
Specific condition
Natural state of feeling : hypothym, stabil, good controlling, echt,
adequate einfuhlung, deep, narrow differentiation scale, fast emotion
flow.
Intellectual condition : memorizing abililty good, concentration ability
good, orientation undisturbed, general knowledge good,
discriminative insight good, allegged level of intelegency cannot
evaluated, discriminative judgment good, intellectual deterioration
absent.
Sensation and perception disorder: illusion and hallucination absent.
Process of Thinking: fast, clear and 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: much
Relation to reality: good (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


No diagnosis

Axis V. Global Assessment of Functioning


80-71: Symptoms temporary and can be overcome,
mild disability in social, work and school.
MULTIAXIAL DIAGNOSIS
F 41.1 General Anxietas Disorder
No diagnosis
No diagnosis
No diagnosis
GAF 80-71
DIFFERENTIAL DIAGNOSIS
THERAPY
PROGNOSIS
Assesment Good Bad

Onset Adult

Relaps Often

Diagnosis General Anxietas disorder

Family Support Good

Medicine Respons Good

Marriage Married

Economy Condition Moderete

Obedience to take Dicipline


medicine
Trigger Overthinking about children

Genetic Nothing

Other disease Nothing


Quo ad vitam : dubia ad bonam
Quo ad fungsionam : dubia ad bonam
Quo ad sanationam : dubia ad bonam

The thing that can make good prognosis : onset, family


support, medicine respons, marriage, economy
condition, obedience to take medicine, genetic, and no
other disease and disorder.

The thing that can increase bad prognosis : relaps and


the trigger.
CASE ANALYSES
The diagnosis of the patient came from medical history
and physical examination. Patients chief complains
anxiety that happen everyday in more than two years.
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.
SCHEME OF DISEASE HISTORY

2012
getting better
2011 2013
1985 Her complaint Her complaint was
Anxiety, return because she
more decreased
palpitation, worried about her son
headache, get and go to hospital and
trouble to sleep, then she go to polyclinic
and easy to cry, M. Djamil Padang. And
Everyday and she routine controlled until
go to hospital 1985 now
The first time she
get therapy she felt
1985 the symptoms
First time she decreased
felt the
symptoms