status psikiatrikus ump
DESCRIPTION
Status Psikiatrikus UmpTRANSCRIPT
STATUS PSIKIATRIKUS
Nama :
NIM :
Semester :
Tanggal :
Pembimbing :
Kegiatan :
BAGIAN ILMU KEDOKTERAN JIWA
RUMAH SAKIT Dr. ERNALDI BAHAR
FAKULTAS KEDOKTERAN UNIVERSITAS
MUHAMMADIYAH PALEMBANG
2015
BAGIAN ILMU KEDOKTERAN JIWA Nomor Status :
FAKULTAS KEDOKTERAN Nomor Registrasi :
UNIVERSITAS SRIWIJAYA Tahun :
PALEMBANG Tanggal Masuk :
Tanggal Meninggal :
STATUS PASIEN JIWA
Nama :.............................................. Laki-laki/Perempuan
Tanggal Lahir/Umur :.............................................. Tempat Lahir :.........................
Status Perkawinan :.............................................. Warga Negara :.........................
Agama :.............................................. Suku Bangsa :.........................
Tingkat Pendidikan :.............................................. Pekerjaan :.........................
Alamat dan nomor telepon keluarga terdekat pasien.............................................................
................................................................................................................................................
Dikirim Oleh :...................................................................................................................
Nama Mahasiswa :..................................................................................
NIM :..................................................................................
Dokter Supervisor / yang mengobati :..................................................................................
Bangsal :..................................................................................
MENGETAHUI
SUPERVISOR
(.......................................)
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STATUS PRESENS TANGGAL :.....................................................................................
STATUS INTERNUS
Keadaan Umum
Sensorium :......................... Suhu :................ Berat Badan :...................
Nadi :......................... Pernafasan :................ Tinggi Badan :...................
Tekanan Darah :......................... Turgor :................ Status Gizi :...................
Sistem Kardiovaskular :.......................................................................................................
Sistem Respiratorik :.......................................................................................................
Sistem Gastrointestinal :.......................................................................................................
Sistem Urogenital :.......................................................................................................
Kelainan Khusus :.......................................................................................................
STATUS NEUROLOGIKUS
Urat Syaraf Kepala (Panca Indera) :.........................................................................
.................................................................................................................................
.................................................................................................................................
Gejala Rangsang Meningeal :.........................................................................
.................................................................................................................................
Gejala Peningkatan Tekanan Intrakranial :.........................................................................
.................................................................................................................................
Mata : - Gerakan :...............................................................................
- Persepsi Mata :...............................................................................
- Pupil : Bentuk.........................Ukuran..............................
Refleks Cahaya............................Refleks Konvergensi.............................
- Refleks Kornea :...............................................................................
- Pemeriksaan Oftalmoskopi :...............................................................................
Motorik : - Tonus :....................................................................................................
- Koordinasi :....................................................................................................
- Turgor :....................................................................................................
- Refleks :....................................................................................................
- Kekuatan :....................................................................................................
Sensibilitas :.................................................................................................
Susunan Syaraf Vegetatif :.................................................................................................
Fungsi Luhur :.................................................................................................
Kelainan Khusus :.................................................................................................
.................................................................................................................................
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PEMERIKSAAN LABORATORIUM YANG DIPERLUKAN
Darah Rutin..........................................................Khusus......................................................
Urine Rutin...........................................................Khusus......................................................
Tinja Rutin...........................................................Khusus......................................................
Liquor Serebrospinalis (Pungsi Lumbal)...............................................................................
PEMERIKSAAN ELEKTROENSEFALOGRAM (EEG)
PEMERIKSAAN RADIOLOGI
BRAIN COMPUTERIZED TOMOGRAPHY SCANNING (CT-SCAN OTAK)
HASIL
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STATUS PSIKIATRIKUS
ALLOANAMNESIS (Boleh lebih dari satu sumber)
Diperoleh dari :........................................................................................
Umur :........................................................................................
Alamat dan Nomor Telepon :........................................................................................
Pendidikan :........................................................................................
Hubungan dengan pasien :........................................................................................
Sebagai patokan dalam melakukan alloanamnesis, perhatikan petunjuk di bawah ini :1. Sebab utama membawa pasien ke Rumah Sakit Jiwa2. Keluhan utama pasien dalam serangan gangguan sekarang (yang didengar oleh
keluarga/sumber alloanamnesis)3. Riwayat perjalanan penyakit sekarang dan yang sebelumnya4. Riwayat dan gambaran kepribadian premorbid masa bayi, masa anak-anak, masa
remaja, dewasa, dan selanjutnya; gambaran ciri-ciri kepribadian premorbid5. Riwayat perkembangan organobiologik, penyakit-penyakit yang pernah diderita6. Riwayat pendidikan, pekerjaan, dan perkawinan7. Keadaan sosial ekonomi pasien atau orang tuanya8. Riwayat keluarga, termasuk gangguan jiwa atau penyakit yang ada hubungannya
dengan gangguan jiwa dalam keluarga, pola asuh orang tua, dan hubungan antar saudara
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AUTOANAMNESIS DAN OBSERVASI
Selama dilakukan autoanamnesis juga sekaligus dilakukan observasi atas sikap dan tingkah laku pasien (bagaimana ekspresi wajah, sikap dan tingkah laku pasien selama berbicara atau menjawab pertanyaan yang diajukan).
Sebelum melakukan pemeriksaan ini, pemeriksa sudah menguasai kerangka yang terdapat pada “IKHTISAR DAN KESIMPULAN AUTOANAMNESIS DAN OBSERVASI” (pada halaman 10), agar pemeriksa dapat menangkap dan mengenal gejala-gejala psikopatologi yang muncul.
Selama autoanamnesis berlangsung, gunakan bahasa yang dimengerti oleh pasien dan jawaban pasien sedapat-dapatnya ditulis dalam kata-kata asli dari pasien (secara verbatim). Gejala-gejala psikopatologi yang tidak muncul secara spontan dapat dilakukan wawancara secara terpimpin, namun usahakan tidak bersifat sugestif.
Hasil autoanamnesis dan observasi ditulis dalam protokol, tulislah yang perlu-perlu saja. Cerita pasien yang tidak perlu diberi tanda ........ yang memisahkan antara bagian cerita pasien yang ditulis sebelum dan sesudahnya.
Hasil autoanamnesis dan observasi ditulis dalam protokol seperti di bawah ini: Kalimat ucapan ditulis dalam tanda petik “...........” dan hasil observasi yang berkaitan ditulis dalam tanda kurung ( ) di belakang kalimat tersebut.
Sebelum penulisan protokol tersebut, terlebih dahulu deskripsikanlah keadaan dan penampilan pasien ketika ditemui untuk diajak wawancara.
PEMERIKSA PASIEN INTERPRETASI
(PSIKOPATOLOGI)
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IKHTISAR DAN KESIMPULAN PEMERIKSAAN PSIKIATRI
(AUTOANAMNESIS DAN OBSERVASI)
KEADAAN UMUM
Kesadaran/Sensorium :.......................................................................................................
Perhatian :.......................................................................................................
Sikap :.......................................................................................................
Inisiatif :.......................................................................................................
Tingkah Laku Motorik :.......................................................................................................
Karangan/Tulisan/Gambaran (bila ada lampirkan)................................................................
Ekspresi Fasial :.......................................................................................................
Verbalisasi :...........................................Cara Bicara :.....................................
Kontak Psikis : - Kontak Fisik :........................................................................................
- Kontak Mata :........................................................................................
- Kontak Verbal :........................................................................................
KEADAAN KHUSUS (SPESIFIK)
1. Keadaan Afektif (Mood) : ...............................................................................................
2. Hidup Emosi
Stabilitas :........................................Dalam-dangkal :.....................................
Pengendalian :........................................Adekuat-Inadekuat :.....................................
Echt-Unecht :........................................Skala Diferensiasi :.....................................
Einfuhlung :........................................Arus Emosi :.....................................
3. Keadaan dan Fungsi Intelek
Daya ingat (amnesia, dsb) :......................................................................
Daya Konsentrasi :......................................................................
Orientasi : Tempat :......................................................................
Waktu :......................................................................
Personal :......................................................................
Luas Pengetahuan umum dan Sekolah :......................................................................
Discriminative Judgement :......................................................................
Discriminative Insight :......................................................................
Dugaan taraf intelegensi :......................................................................
Kemunduran intelektual (demensia, dsb) :......................................................................
4. Kelainan Sensasi dan Persepsi
Ilusi :...................................................................................................................
Halusinasi :...................................................................................................................
..........................................................................................................................................
...................................................................................................................(deskripsikan)
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5. Keadaan Proses Berpikir
Psikomotilitas :....................................................................................................
Mutu proses berpikir :....................................................................................................
Arus Pikiran
Flight of ideas.............................................Inkoherensi............................................
Sirkumstansial.............................................Tangensial.............................................
Terhalang....................................................Terhambat.............................................
Perseverasi..................................................Verbigerasi............................................
Lain-lain.....................................................................................................................
Isi Pikiran
Pola Sentral.................................................Rasa permusuhan/dendam....................
Waham.......................................................................................................................
....................................................................................................................................
.............................................................................................................(deskripsikan)
Fobia...........................................................Hipokondria..........................................
Konfabulasi.................................................Banyak sedikit isi pikiran......................
Perasaan inferior.........................................Perasaan berdosa/salah..........................
Kecurigaan (belum taraf waham)...............................................................................
Lain-lain.....................................................................................................................
Pemilikan Pikiran
Obsesi.........................................................................................................................
Alienasi......................................................................................................................
Bentuk Pikiran
Autistik/dereistik.........................................Simbolik................................................
Paralogik.....................................................Simetrik.................................................
Konkritisasi.................................................Lain-lain................................................
Lain-lain :....................................................................................................
6. Keadaan Dorongan Instinktual dan Perbuatan
Abulia/Hipobulia...............................................Vagabondage........................................
Stupor................................................................Pyromania.............................................
Raptus/Impulsivitas...........................................Mannerisme...........................................
Kegaduhan Umum............................................Autisme.................................................
Deviasi Seksual.................................................Logore...................................................
Ekopraksi..........................................................Mutisme................................................
Ekolalia.............................................................Lain-lain................................................
7. Kecemasan ( anxiety ) yang terlihat secara nyata ( overt ) (ada, tidak ada) ........................
8. Reality Testing Ability .....................................................................................................
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PEMERIKSAAN LAIN-LAIN
1. Evaluasi psikologik (oleh Psikolog) tanggal :.......................................................
2. Evaluasi sosial (oleh Ahli Pekerja Sosial) tanggal :.......................................................
3. Evaluasi lain-lain tanggal :.......................................................
(Bila ada, hasilnya dilampirkan)
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FOLLOW UP
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RESUME
I. IDENTIFIKASI
II. STATUS INTERNUS
III.STATUS NEUROLOGIKUS
IV. STATUS PSIKIATRIKUS
Sebab Utama :
Keluhan Utama :
Riwayat Perjalanan Penyakit
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FORMULASI DIAGNOSTIK
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DIAGNOSIS MULTIAKSIAL
AKSIS I :............................................................................................................................
AKSIS II :............................................................................................................................
AKSIS III :............................................................................................................................
AKSIS IV :............................................................................................................................
AKSIS V :............................................................................................................................
DIAGNOSIS DIFERENSIAL
TERAPI
PROGNOSIS
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