Nomor Status
FAKULTAS KEDOKTERAN
Nomor Registrasi
UNIVERSITAS SRIWIJAYA
Tahun
PALEMBANG
Tanggal Masuk
Tanggal Meninggal :
STATUS PASIEN JIWA
Nama
:.............................................. Laki-laki/Perempuan
:.........................
Status Perkawinan
:.........................
Agama
:.........................
Tingkat Pendidikan
:.............................................. Pekerjaan
:.........................
:...................................................................................................................
Nama Mahasiswa
:..................................................................................
NIM
:..................................................................................
:..................................................................................
MENGETAHUI
SUPERVISOR
(.......................................)
2
STATUS PRESENS TANGGAL
:.....................................................................................
STATUS INTERNUS
Keadaan Umum
Sensorium
:......................... Suhu
Nadi
:...................
:...................
:.......................................................................................................
:.......................................................................................................
Kelainan Khusus
:.......................................................................................................
STATUS NEUROLOGIKUS
:.........................................................................
.................................................................................................................................
Gejala Rangsang Meningeal
:.........................................................................
.................................................................................................................................
Gejala Peningkatan Tekanan Intrakranial :.........................................................................
.................................................................................................................................
Mata : - Gerakan
:...............................................................................
- Persepsi Mata
:...............................................................................
- Pupil
: Bentuk.........................Ukuran..............................
Refleks Cahaya............................Refleks Konvergensi.............................
- Refleks Kornea
:...............................................................................
:....................................................................................................
- Koordinasi :....................................................................................................
- Turgor
:....................................................................................................
- Refleks
:....................................................................................................
- Kekuatan
:....................................................................................................
Sensibilitas
:.................................................................................................
:.................................................................................................
Fungsi Luhur
:.................................................................................................
Kelainan Khusus
:.................................................................................................
.................................................................................................................................
3
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
4
STATUS PSIKIATRIKUS
ALLOANAMNESIS (Boleh lebih dari satu sumber)
Diperoleh dari
:........................................................................................
Umur
:........................................................................................
:........................................................................................
:........................................................................................
7
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 perluperlu 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)
10
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 : ............................................................................................................
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)
5. Keadaan Proses Berpikir
Psikomotilitas
:....................................................................................................
Mutu proses berpikir :....................................................................................................
11
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.....................................................................................................
..........................................................................................................................................
12
PEMERIKSAAN LAIN-LAIN
1. Evaluasi psikologik (oleh Psikolog) tanggal
:.......................................................
:.......................................................
13
FOLLOW UP
14
RESUME
I. IDENTIFIKASI
III.STATUS NEUROLOGIKUS
Keluhan Utama :
Riwayat Perjalanan Penyakit
15
16
17
FORMULASI DIAGNOSTIK
18
DIAGNOSIS MULTIAKSIAL
AKSIS I
:............................................................................................................................
AKSIS II :............................................................................................................................
AKSIS III :............................................................................................................................
AKSIS IV :............................................................................................................................
AKSIS V :............................................................................................................................
DIAGNOSIS DIFERENSIAL
TERAPI
PROGNOSIS