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STATUS PSIKIATRIKUS

Nama : Siti Shaihany Yustikawari

NIM : 712017057
Tanggal : November 2018
Pembimbing : Dr. Abdullah Shahab, Sp.KJ., MARS
Kegiatan : Ujian

BAGIAN ILMU KEDOKTERAN JIWA

RUMAH SAKIT Dr. ERNALDI BAHAR
PROVINSI SUMATERA SELATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH PALEMBANG
2018
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BAGIAN ILMU KEDOKTERAN JIWA Nomor Status :

FAKULTAS KEDOKTERAN Nomor Registrasi :
UNIVERSITAS MUHAMMADIYAH Tahun :
PALEMBANG Tanggal Masuk :

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 Jiwa
2. Keluhan utama pasien dalam serangan gangguan sekarang (yang didengar
oleh keluarga/sumber alloanamnesis)
3. Riwayat perjalanan penyakit sekarang dan yang sebelumnya
4. Riwayat dan gambaran kepribadian premorbid masa bayi, masa anak-anak,
masa remaja, dewasa, dan selanjutnya; gambaran ciri-ciri kepribadian
premorbid
5. Riwayat perkembangan organobiologik, penyakit-penyakit yang pernah
diderita
6. Riwayat pendidikan, pekerjaan, dan perkawinan
7. Keadaan sosial ekonomi pasien atau orang tuanya
8. 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

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(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
.....................................................................
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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