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Case Report A 50 years old man was coming to Polyclinic of Prof. HB.

Saanin Hospital Padang on April 28th, 2011 at 10.00 am by himself with sleeping difficulty because has much anxiety complain. Patient identity: Name Sex Age Place of birth Marrietal status Religion Citizen Ethnical Group A. Internal Status Consciousness Blood pressure Pulse Breath Temperature Digestive system Specific disorder B. Neurological Status Central nervous system : Eyes Motoric Sensibility Specific disorder Autoanamnesa : : : : : No disorder found No nistagmus, no diplopia eutonus, no disorder No disorder found No disorder found : : : : : : : Compos Mentis Cooperative 120/80 mmHg 88 x per minute 22 x per minute 36,50C No disorder found No disorder found No disorder found : : : : : : : : Y Male 50 years old Padang Married Islam Indonesia Minangkabau

Cardiovascular system :

1. Present complain of patient Patient has much anxiety,therefore he has difficulty to sleep. This complain has occurred since he was in senior high school. He continously took anti anxiety medication such as ativan ever since. If he doesnt take the medicine, he will become nervous, got headache, restless, and lost appetite.
2. History of illness:

When the patient was in junior high school, he felt inferior for himself. He felt nervous and tense when he meet somebody new because of his pimply face. So, he looked for psychiatric help to heal the anxiety. Since that, he always took medication such as ativan and lexotan. He took it routinely according to doctors instruction. If he doesnt take it, he will feel nervous, headache and difficult to sleep and eat. Beside taking a medication, the patient also smoked to deal with the anxiety. He smoked two packs per day. The pasien has introvert personality. He doesnt like to tell others about his problem, including his wife. Hed rather to keep it for himself. Sometimes, he feels suspicious when seeing other people talking to each other as if they are talking about him. The patient also told that he prefer being alone, doesnt talking too much, often muse, but he admitted there is nothing he was thinking about. 3. Premorbid history Infant Childhood Adolescence : : : born spontaneously, birth was assisted by midwife, no history of jaundice, cyanosis, and seizure. Growth and development suitable for children his age. got a few friends, lack of confidence, introvert personality

4. Social economy Background Living with his wife and one daughter in a permanent house, with electricity and get fresh water from PDAM, had 1 motorcycle. He works as a clothes trader in Pasar Raya Padang and has 3 stores there. 5. Educational background Elementary School : SDN 54 Padang Pasir, graduate in 6 years, average achievement

Junior High School : SMP 2 Padang, graduate in 3 years, average achievement Senior High School: SMA 3 Padang, graduate in 3 years, average achievement 6. Family history of illness There were no family members that has ever been had the same symptom like this

7. Graphich of illness

1981

2011

Summary Of phsyciatric examination


1. General appereance

Counciousness/sensorial Attitude Motoric Facial expression Verbalization Physic contact Attention Initiative 2. Specific condition A. Affective

: : : : : : : :

compos mentis/good cooperative active rich fluently could be done/appropriate/long enough good present

1. Affective condition

euthim stable controlled : : : echt adequate shallow : fast narrow

2. Emotional :
a. b. c. d. e. f. g.

Stability : Control : Echt/unecht Einfuhlung Deep/shallow

Differentiation scale Emotional flow : Memory : Concentration : normal : Knowledge enough :

B. Intellectual condition of function


a. b. c. Orientation d. e. f. g.

enough can not be predicted not disturbed average : not

Discriminative insight : Intelligence prediction : Discriminative judgment

disturbed C. Sensation and perception abnormanlities

1. Illusion 2. Hallucination

: : : : : : :

none none none none none none : : fast

Acoustic Visual Olfactoric Tactil Gustatoric D. Thought process condition


1. 2. a. Clear and sharp

Speed of thought processs Quality of thought process : : : : : : : clear and sharp none none none none none none none none none none none none much none none

b. Incoherent
c. Blocking d. Resistence

e. Flight of ideas f. Verbigeration g. Preservation 3. a. b. c. d. e. f. g.


h. i.

Thought condition Central pattern : Phobia : Obsession Delusion : Suspicion Confabulation Repultion Much/little Feeling guilty Hypochondria Others : none : none : : : : : : none

Inferior feeling :

j. k. l.

E. Instingtual drive and behavior abnormalities

a. Abulia b. Stupor c. Raptus/impulsivity d. Excitement state e. Sexual deviation f. Echopraxia g. Vagabondage h. Pyromani

: : : : : : : : : : : :

none none none none none none none none none none present, a lot not disturbed in behavior, feeling and

i. Mannerism
j. Others F. Overt anxiety G. Reality testing ability

thinking RESUME MULTIPLE AXIS Asis I. clinic syndrome Has much anxiety,therefore he has difficulty to sleep since high school, continously took anti anxiety medication, if he doesnt take the medicine, he will become nervous, got headache, restless, and lost appetite. Physiatric examination: General appereance : compos mentis, cooperative, active, rich, can speak fluently and clear, psychic contact could be done, appropriately and long enough. Specific condition:
a. Affective condition : euthim, stable, controlled, echt, adequate, shallow, narrow, fast. b. Intellectual condition and function: good memory, good concentration, orientation in a

good state, knowledge cant be predicted, discriminative insight and judgment are not disturbed.
c. Sensation and perception abnormalities: there is no illusion or hallucination d. Thought process condition: fast, clear and sharp enough e. Instinctual drive and behavior abnormalities: no disorder f. Overt anxiety: present, a lot g. Reality testing ability, not disturbed in behavior, feeling and thinking

Axis II : personality disorder and mental retardation disorders Personality: got a few friends, lack of confidence, introvert personality Mental retardation: none Axis III : general medical condition Theres no history of malaria, typhoid, capitis trauma, and other disease that need to be hospitalized Axis IV : Physcosocial stressor dan environment None Axis V : Social : visist friends, mutual assistance, pray in mosque, and attend invitation can be done Daily activity: can do it self Freetime activity: can be done

Multiple axis diagnosis


I. F 41.1 Generalized Anxiety Disorder II. F 60.6 Anxious Personality Disorder

III. No diagnosis IV. No stressor V. GAF 71-80 Diferensial diagnosis


I. F 41.2 mixed anxiety and depressive disorders II. F 41.3 Other mixed anxiety disorders

Therapy Alprazolam 2x1 tab @ 0,5 mg Clobazam 2x tab @ 10 mg Prognosis Clinis Functional : dubia at bonam : dubia at bonam

Social

: dubia at bonam