Professional Documents
Culture Documents
General Condition
Awareness : Composmentis
Attention : good
Attitude : Cooperative
Inisiative : good
Motoric behaviour : active
Facial expression : poor
Speech and verbal : speak fluently
and clear
Physical contact : could be done,
natural, and long-time
B. Intelectual Funnction
Memory
(amnesia)
: good
Concentration
: adequat
Orientation
(time, spatial, personal, situation)
: undisturbed
general knowledge
: good
discriminative
insight
: good
alleged level of intelegency :
cannot
evaluated
discriminative judgment
: good
intelectual deterioration
:
absent
D. Way of Thinking
1. Psikomobilitas : fast
2. Thingking process
a. clear and sharp : clear but not sharp
b. Sirkumstansial : absent
Inkoherrent
: absent
Sperrung : absent
Hemmung
: absent
Flight of ideas : absent
Verbigerasi Persevarative ( Persevaratich )
absent
3. Contents
a. Central pattern : absent
Phobia : absent
Obsess : absent
Dellusion
: absent
Suspicion
: absent
Confabulation : absent
Animosity/revenge : absent
Inferior feeling : absent
Much/less
: less
Guilty feeling: absent
Hippochondria : absent
Others : -
Sensation
Instinctual
encouragement:
abulia absent, stupor absent,
raptus absent, excitement state
absent, sexual deviation absent,
echophraxia absent,
vagabondage absent, pyromania
absent, mannerisme absent.
Anxiety: yes
Relation to reality: good
(behavior, feeling, thinking)
Axis V. Global
Assessment of
Functioning
No diagnosis
MULTIAXIAL DIAGNOSIS
Axis I : F 41.1 General Anxiety
Disorder
Axis II : No diagnosis
Axis III : No diagnosis
Axis IV : No diagnosis
Axis V : GAF 80-71
DIFFERENTIAL DIAGNOSIS
F 41 Panic disorder
THERAPY
Pharmacotherapy :
Alprazolam 1 x tab@ 0,5 mg
Amitriptyline 1 x tab @ 25 mg
Psychoteraphy
- Patient
Supportif psycotherapy
Psychoeducation
- Family : Psychoeducation about
Patient disorder
Teraphy
PROGNOSIS
Assesment
Good
Onset
Adult
Relaps
Often
Diagnosis
Family Support
Good
Medicine Respons
Baik
Marriage
Married
Economy Condition
Moderete
Dicipline
Trigger
Genetic
Nothing
Nothing
Bad
Quo
Patients
chief
complains
:
anxiety
(everyday
in more than six month),
Medical palpitation, headache, get a trouble for
History sleep and easy to cry
No drunk and using drug history.
on
Diagnosy
PPGDJ III
1. anxiety symptoms
showed everyday for
several weeks until
month and its free
floating.
2. Tremor, palpitation
and headache
3. No drunk or using
drug history
General anxiety
disorders.
DSM IV
1. Anxiety symptomps
showed during a day
and everyday and
thats happen more 6
month.
2. Difficult to controlled
the anxiety.
3. Anxiety can be
meaningful to make
clinical disorder.
General anxiety
disorders.
Pharmacotheraphy
Alprazolam 1 x tab @ 2 mg, Amitriptyline 1
x tab @ 25 mg.
Psychotherapy :
1. Patient : Supportif psycotherapy &
Psychoeducation
II. Family : Psychoeducation about : Patient
disorder and Teraphy