copy of status psikiatrikus
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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
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,-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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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
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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
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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
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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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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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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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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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St"%6r................................................................ Pyromania
...........................................................................
(a%t"s9Im%"lsi
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PEMERIKSAAN LAIN-LAIN
1. / tanggal :.......................................................
3. /
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FOLLOW UP
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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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FORMULASI DIAGNOSTIK
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DIAGNOSIS MULTIAKSIAL
&SIS I :............................................................................................................................
&SIS II :............................................................................................................................
&SIS III :............................................................................................................................
&SIS I :............................................................................................................................
&SIS :............................................................................................................................
DIAGNOSIS DIFERENSIAL
TERAPI
PROGNOSIS
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