copy of status psikiatrikus

8/16/2019 Copy of Status Psikiatrikus

1/22

STATUS PSIKIATRIKUS

Nama : Febry Setiawan

NIM : 712014038

Semester : 10Tanggal :

Pembimbing : Dr. b!"lla# S#a#ab$ S%.&'. M(S

&egiatan : )*ian +#ir Stase

,-IN IM) &/D&T/(N 'I

F&)TS &/D&T/(N

)NI/(SITS M)MMDI P/M,N-

()M S&IT Dr. /(NDI ,(

P(INSI S)MT/( S/TN

2015

0


2/22

,-IN IM) &/D&T/(N 'I N6m6r Stat"s :

F&)TS &/D&T/(N N6m6r (egistrasi :

)NI/(SITS S(II' Ta#"n : 2015

P/M,N- Tanggal Mas"+ :

Tanggal Meninggal :

STT)S PSI/N 'I

Nama : S"laningsi........................... a+ila+i9Perem%"an

Tanggal a#ir9)m"r : 11 Mei 14;951 ta#"n.......... Tem%at a#ir : Palembang.......

Stat"s Per+awinan : S"!a# meni+a#..................... arga Negara : In!6nesia.........

gama : Islam..................................... S"+" ,angsa : Palembang.......

Ting+at Pen!i!i+an : SM..................................... Pe+er*aan : iraswasta......

lamat !an n6m6r tele%6n +el"arga ter!e+at %asien.............................................................

&el"ra#an S"+a*aya$ Palembang...........................................................................................

Di+irim le# : Datang Sen!iri..........................................................................................

Nama Ma#asiswa : Febry Setiawan........................................................

NIM : 712014038...............................................................

D6+ter S"%er

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3/22

STT)S P(/S/NS TN-- : ....................................................................................

STATUS INTERNUS

&ea!aan )m"m

Sens6ri"m :......................... S"#" :................ ,erat ,a!an :...................

Na!i :......................... Pernaasan :................ Tinggi ,a!an :............ .......

Te+anan Dara# :......................... T"rg6r :................ Stat"s -i?i :...................

Sistem &ar!i6


4/22


5/22

PEMERIKSAAN LABORATORIUM YANG DIPERLUKAN

Dara# ("tin.........................................................."s"s......................................................

)rine ("tin..........................................................."s"s......................................................

Tin*a ("tin..........................................................."s"s......................................................

iB"6r Serebr6s%inalis =P"ngsi "mbal>...............................................................................

PEMERIKSAAN ELEKTROENSEFALOGRAM (EEG)

PEMERIKSAAN RADIOLOGI

BRAIN COMPUTERIZED TOMOGRAPHY SCANNING (CT-SCAN OTAK)

HASIL

4


6/22

STATUS PSIKIATRIKUS

ALLOANAMNESIS =,6le# lebi# !ari sat" s"mber>

Di%er6le# !ari :

)m"r :

lamat !an N6m6r Tele%6n :

Pen!i!i+an :

"b"ngan !engan %asien :

Sebagai %at6+an !alam mela+"+an all6anamnesis$ %er#ati+an %et"n*"+ !i bawa# ini :

1. Sebab "tama membawa %asien +e ("ma# Sa+it 'iwa

2. &el"#an "tama %asien !alam serangan gangg"an se+arang =yang !i!engar 6le#

+el"arga9s"mber all6anamnesis>

3. (iwayat %er*alanan %enya+it se+arang !an yang sebel"mnya

4. (iwayat !an gambaran +e%riba!ian %rem6rbi! masa bayi$ masa ana+ana+$

masa rema*a$ !ewasa$ !an selan*"tnyaC gambaran @iri@iri +e%riba!ian

%rem6rbi!

;. (iwayat %er+embangan 6rgan6bi6l6gi+$ %enya+it%enya+it yang %erna#!i!erita

5. (iwayat %en!i!i+an$ %e+er*aan$ !an %er+awinan

7. &ea!aan s6sial e+6n6mi %asien ata" 6rang t"anya

8. (iwayat +el"arga$ termas"+ gangg"an *iwa ata" %enya+it yang a!a

#"b"ngannya !engan gangg"an *iwa !alam +el"arga$ %6la as"# 6rang t"a$ !an

#"b"ngan antar sa"!ara

;


7/22

5


8/22

7


9/22

AUTOANAMNESIS DAN OBSERVASI

Selama !ila+"+an a"t6anamnesis *"ga se+alig"s !ila+"+an 6bser.

Sebel"m mela+"+an %emeri+saan ini$ %emeri+sa s"!a# meng"asai +erang+ayang ter!a%at %a!a I&TIS( DN &/SIMP)N )TNMN/SIS DN

,S/(SIE =%a!a #alaman 10>$ agar %emeri+sa !a%at menang+a% !an mengenal

ge*alage*ala %si+6%at6l6gi yang m"n@"l.

Selama a"t6anamnesis berlangs"ng$ g"na+an ba#asa yang !imengerti 6le#

%asien !an *awaban %asien se!a%at!a%atnya !it"lis !alam +ata+ata asli !ari %asien

=se@ara verbatim>. -e*alage*ala %si+6%at6l6gi yang ti!a+ m"n@"l se@ara s%6ntan !a%at

!ila+"+an wawan@ara se@ara ter%im%in$ nam"n "sa#a+an ti!a+ bersiat s"gesti.

asil a"t6anamnesis !an 6bser

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10/22


11/22

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12/22

IKHTISAR DAN KESIMPULAN PEMERIKSAAN PSIKIATRI

(AUTOANAMNESIS DAN OBSERVASI)

KEADAAN UMUM

&esa!aran9Sens6ri"m :.......................................................................................................

Per#atian :.......................................................................................................

Si+a% :.......................................................................................................

Inisiati :.......................................................................................................

Ting+a# a+" M6t6ri+ :.......................................................................................................

&arangan9T"lisan9-ambaran =bila a!a lam%ir+an>................................................................

/+s%resi Fasial :.......................................................................................................

erbalisasi :...........................................Aara ,i@ara :.....................................

&6nta+ Psi+is : &6nta+ Fisi+ :........................................................................................

&6nta+ Mata :........................................................................................

&6nta+ erbal :........................................................................................

KEADAAN KHUSUS (SPESIFIK)

1. &ea!aan e+ti =M66!> : ...............................................................................................

2. i!"% /m6si

Stabilitas :........................................Dalam!ang+al :

Pengen!alian :........................................!e+"atIna!e+"at :

Echt-Unecht :........................................S+ala Dierensiasi :

Einfuhlung :........................................r"s /m6si :

3. &ea!aan !an F"ngsi Intele+

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13/22

Daya ingat =amnesia$ !sb> :

Daya &6nsentrasi :

rientasi : Tem%at :

a+t" :

Pers6nal :

"as Pengeta#"an "m"m !an Se+6la# :

Discriminative Judgement :

Discriminative Insight :

D"gaan tara intelegensi :

&em"n!"ran intele+t"al =!emensia$ !sb> :

4. &elainan Sensasi !an Perse%si

Il"si :

al"sinasi :

....................................................................................................................................

...................................................................................................................=!es+ri%si+an>

;. &ea!aan Pr6ses ,er%i+ir

Psi+6m6tilitas :

M"t" %r6ses ber%i+ir :

r"s Pi+iran

Flig#t 6 i!eas.............................................In+6#erensi

.....................................................................

Sir+"mstansial.............................................Tangensial

.....................................................................

Ter#alang.....................................................Ter#ambat

.....................................................................

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14/22

Perse

F6bia...........................................................i%6+6n!ria

.....................................................................&6nab"lasi.................................................,anya+ se!i+it isi %i+iran

.....................................................................

Perasaan ineri6r.........................................Perasaan ber!6sa9sala#

.....................................................................

&e@"rigaan =bel"m tara wa#am>

..............................................................................................................................

ainlain

..............................................................................................................................

Pemili+an Pi+iran

bsesi

..............................................................................................................................

lienasi

..............................................................................................................................

,ent"+ Pi+iran

"tisti+9!ereisti+.........................................Simb6li+

.....................................................................

Paral6gi+.....................................................Simetri+ .....................................................................

&6n+ritisasi.................................................ainlain

.....................................................................

ainlain :

5. &ea!aan D6r6ngan Instin+t"al !an Perb"atan

b"lia9i%6b"lia...............................................Vagabondage

...........................................................................

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15/22

St"%6r................................................................ Pyromania

...........................................................................

(a%t"s9Im%"lsi


16/22

PEMERIKSAAN LAIN-LAIN

1. / tanggal :.......................................................

3. /


17/22

FOLLOW UP

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18/22

RESUME

I. IDENTIFIKASI

II. STATUS INTERNUS

III.STATUS NEUROLOGIKUS

IV. STATUS PSIKIATRIKUS

Sebab )tama :

&el"#an )tama :

(iwayat Per*alanan Penya+it

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19/22

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20/22

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21/22

FORMULASI DIAGNOSTIK

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22/22

DIAGNOSIS MULTIAKSIAL

&SIS I :............................................................................................................................

&SIS II :............................................................................................................................

&SIS III :............................................................................................................................

&SIS I :............................................................................................................................

&SIS :............................................................................................................................

DIAGNOSIS DIFERENSIAL

TERAPI

PROGNOSIS

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