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STATUS PSIKIATRIKUS

Nama :
NIM :
Semester :
Tanggal :
Pembimbing :
Kegiatan :

BAGIAN ILMU KEDOKTERAN JIWA

FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA
RUMAH SAKIT Dr. ERNALDI BAHAR
PROVINSI SUMATERA SELATAN
2020
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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 :........................................................................................
Keluhan Utama:

RPP:

RPD:

RPK:
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AUTOANAMNESIS DAN OBSERVASI

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 :........................................Kedalaman :.....................................
Pengendalian :........................................Adequacy :.....................................
Echt/Unecht :........................................Skala Diferensiasi :.....................................
Einfuhlung :........................................Arus Emosi :.....................................
3. Keadaan dan Fungsi Intelek
Daya ingat :......................................................................
Daya Konsentrasi :......................................................................
Orientasi : Tempat :......................................................................
Waktu :......................................................................
Personal :......................................................................
Luas Pengetahuan umum dan Sekolah :......................................................................
Discriminative Judgement :......................................................................
Discriminative Insight :......................................................................
Dugaan taraf intelegensi :......................................................................
Kemunduran intelektual :......................................................................
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
Kuantitas.....................................................Pola Sentral...........................................
Waham.......................................................................................................................
....................................................................................................................................
.............................................................................................................(deskripsikan)
Ide terfiksir.................................................................................................................
Fobia...........................................................Hipokondria..........................................
Konfabulasi.................................................Rasa permusuhan/dendam....................
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........................................
Katatonia...........................................................Kompulsi...............................................
Raptus/Impulsivitas...........................................Mannerisme...........................................
Kegaduhan Umum............................................Autisme.................................................
Deviasi Seksual.................................................Logore...................................................
Ekopraksi..........................................................Mutisme................................................
Ekolalia.............................................................Lain-lain................................................
7. Kecemasan (anxiety)........................................................................................................

8. Reality Testing Ability.....................................................................................................

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PEMERIKSAAN LAIN-LAIN

1. Evaluasi psikologik (oleh Psikolog) tanggal : tidak dilakukan..............................

2. Evaluasi sosial (oleh Ahli Pekerja Sosial) tanggal : tidak dilakukan..............................
3. Evaluasi lain-lain tanggal : tidak dilakukan..............................
(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
Aksis I

Tabel 1. Kriteria Diagnosis Skizofrenia

A. Gejala Karakteristik
Gejala Kunci: Dua atau lebih  Aku copas dari anamnesis agek
gejala berikut yang muncul √
dalam satu bulan
1) Waham (cukup satu bila
waham bizar)
2) Halusinasi (cukup satu bila √
halusinasi komentar atau
diskusi)
3) Bicara terdisorganisasi (kacau) -
4) Perilaku terdisorganisasi (kacau) -
atau katatonik
5) Gejala negatif -
B. Disfungsi Sosial/ Pekerjaan
Terdapat penurunan yang jelas -
dalam fungsi sosial, pekerjaan, atau
mengurus diri
C. Durasi
Lama gangguan setidaknya enam -
bulan, dengan satu bulan
menunjukkan gejala yang jelas
D. Gangguan mood dan
skizoafekstif -
Kriteria untuk gangguan mood,
gangguan mental organik, dan
gangguan akibat zat tidak dipenuhi
E. Kondisi medis umum dan zat
Gangguan tersebut tidak
disebabkan efek fisiologis langsung -
suatu zat (obat yang
disalahgunakan atau obat medis)
atau kondisi medis umum
F. Hubungan dengan gangguan -
perkembangan pervasi
Bila ada riwayat Autistic Disorder
atau gangguan PDD lainnya,
diagnosa tambahan skizofrenia
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hanya dibuat bila halusinasi atau

delusi yang menonjol, selama
paling tidak 1 bulan
KESAN:
Pada pasein di dapatkan tiga point dari gejala karakteristik (waham, halusinasi dan gejala
negatif) dan gejala lainnya yang memenuhi kriteria diagnostik skizofrenia.

Tabel 2. Kriteria tambahan untuk skizofrenia paranoid:

Pedoman Diagnostik Terpenuhi/ Tidak Terpenuhi
(PPDGJ-III)
Halusinasi dan/atau waham harus Terpenuhi
menonjol  Halusinasi visual (+)
Halusinasi yang mengancam pasien atau  Halusinasi auditorik (+)
memberi perintah  Waham kendali (+)

Halusinasi pembau atau pengecap rasa, atau Terpenuhi

bersifat seksual, atau lain - lain perasaan
tubuh
Waham dapat berupa hampir setiap jenis, Terpenuhi
tetapi waham dikendalikan, dipengaruhi, dan  Waham kendali (+)
keyakinan di kejar – kejar.  Waham kejar (+)
Gangguan afektif Tidak terpenuhi
Dorongan kehendak dan pembicaraan,
serta gejala katatonik secara relative
tidak nyata/ tidak menonjol
KESAN:
Tabel di atas menunjukkan pasien pada kasus memenuhi kriteria diagnosis Skizofrenia
paranoid (F20.0).

Aksis II
R 46.8 Diagnosis aksis II tertunda. Diagnosis pada aksis II belum dapat ditegakkan
karena gejala pada diagnosis aksis I masih menyamarkan (kemungkinan) gangguan
kepribadian yang dimiliki.

Aksis III
Tidak ada diagnosis

Aksis IV
Pemahaman keluarga yang kurang terhadap kondisi pasien.
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Aksis V
Dilihat dari gejala yang menetap yang dimiliki pasien dan adanya riwayat ingin
membunuh anak tirinya. Dengan demikian skala GAF pada pasien ini adalah 20-11.
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DIAGNOSIS MULTIAKSIAL

AKSIS I : F.20.0 Skizofrenia Paranoid...............................................................................

AKSIS II : R 46.8 Diagnosis aksis II tertunda.....................................................................
AKSIS III : Tidak ada diagnosis...........................................................................................
AKSIS IV : Pemahaman keluarga yang kurang terhadap kondisi pasien.............................
AKSIS V : GAF Scale 20-11...............................................................................................

DIAGNOSIS DIFERENSIAL

TERAPI

1. Risperidone 2 x 2 mg PO
2. THP 1 x 1 mg PO
3. Clozapine 1 x 25 mg

PROGNOSIS

Quo ad vitam : bonam

Quo ad functionam : bonam
Quo ad sanationam : dubia ad bonam