STATUS PSIKIATRIKUS
Nama :
NIM :
Semester :
Tanggal :
Pembimbing :
Kegiatan :
MENGETAHUI
SUPERVISOR
(.......................................)
2
Keadaan Umum
Sensorium :......................... Suhu :................ Berat Badan :...................
Nadi :......................... Pernafasan :................ Tinggi Badan :...................
Tekanan Darah :......................... Turgor :................ Status Gizi :...................
STATUS NEUROLOGIKUS
Darah Rutin..........................................................Khusus......................................................
Urine Rutin...........................................................Khusus......................................................
Tinja Rutin...........................................................Khusus......................................................
Liquor Serebrospinalis (Pungsi Lumbal)...............................................................................
PEMERIKSAAN RADIOLOGI
BRAIN COMPUTERIZED TOMOGRAPHY SCANNING (CT-SCAN OTAK)
HASIL
4
STATUS PSIKIATRIKUS
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 :........................................................................................
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
FOLLOW UP
14
RESUME
I. IDENTIFIKASI
III.STATUS NEUROLOGIKUS
FORMULASI DIAGNOSTIK
18
DIAGNOSIS MULTIAKSIAL
AKSIS I :............................................................................................................................
AKSIS II :............................................................................................................................
AKSIS III :............................................................................................................................
AKSIS IV :............................................................................................................................
AKSIS V :............................................................................................................................
DIAGNOSIS DIFERENSIAL
TERAPI
PROGNOSIS