BED SITE TEACHING

Faza Nurul Wardhani PRESEPTOR:

12100118578 Gemah Nuripah, dr., Sp.Kj
Tarliah Puspitasari
12100118586

PROGRAM PENDIDIKAN PROFESI DOKTER

SMF ILMU KESEHATAN JIWA
RS MUHAMMADIYAH BANDUNG
IDENTITAS PASIEN
Nama : Nn. F
Jenis Kelamin : Perempuan
Usia : 20 tahun
Tempat tinggal : Margahayu raya
Agama : Islam
Suku : Sunda
Pekerjaan : Mahasiswi
Pendidikan terakhir : SMA
Status : Belum Menikah
Tanggal Pemeriksaan : Rabu, 4 Maret 2020
Keluhan Utama
Kontrol pengobatan depresi

Pasien merasa sedih

 RIWAYAT PENYAKIT
SEKARANG
Keluhan sedih ini dirasakan sejak 2 hari yang lalu karena dilarang berteman dengan
sahabat perempuannya oleh ibunya. Semenjak saat itu pasien mulai berbicara sendiri, merasa
mudah lelah, tidak keluar kamar, sulit fokus, mudah tersinggung, dan merasa tidak berguna.
Pasien merasa pikiran dirinya dapat dikendalikan, dipengaruhi, diambil, dimasukkan,
disebarluaskan, dan memiliki pikiran bunuh diri terus menerus. Pasien merasa memiliki
perasaan bersalah dan patut dihukum. Keluhan disertai merasa marah kepada ibunya dan
melampiaskannya dengan berkata-kata kasar kepada teman-temannya. Awalnya pasien
dibawa ke IGD RS Muhammadiyah dengan percobaan bunuh diri pada 6 hari yang lalu dan
tidak mau pergi ke kampus.
 RIWAYAT PENYAKIT
SEKARANG
Telah diberikan pengobatan selama 1 minggu dengan kontrol 1x dan respon
pengobatan baik. Saat ini pasien menjadi dapat tidur, kebiasaan mandi & makan kembali
normal. Saat ini pasien sudah memiliki keinginan untuk kuliah. Namun masih merasa
kebingungan dengan kondisi dia saat ini.

Pasien menyangkal mendengarkan, melihat, mencium, mengecap, dan

merasakan sesuatu yang orang lain tidak mengalami hal tersebut; Pasien menyangkal
memiliki riwayat trauma kepala, kejang, demam tinggi, penggunaan obat-obatan atau zat-
zat yang terlarang, rasa senang yang berlebihan ataupun melakukan aktivitas yang
berlebihan, dan menyangkal memiliki ide untuk bunuh diri. Pasien menyangkal memiliki
kekuatan lebih dari orang lain, merasa dikejar oleh suatu kekuatan tertentu dari luar.
RIWAYAT PENYAKIT PSIKIATRIK
Serangan pertama sejak 1 minggu yang lalu
dan sebelumnya tidak pernah mengalami hal
yang sama.
RIWAYAT MEDIK

Tidak ada riwayat medik.

Get a modern
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Presentation that is
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 RIWAYAT KELUARGA

TIDAK ADA ANGGOTA KELUARGA YANG

MENGALAMI KELUHAN YANG SAMA
 Masa Dikandungan Masa Bayi Dan Masa Sekolah
Dan Persalinan Kanak-kanak Dan Pubertas

RIWAYAT TIDAK DITANYAKAN TIDAK DITANYAKAN TIDAK DITANYAKAN

PRIBADI
• Keadaan umum : Pasien tampak sehat
PEMERIKSAAN
• GCS : 15 E4M6V5

• Tekanan darah : Tidak dilakukan FISIK

• Nadi : Tidak dilakukan

• Respirasi : Tidak dilakukan

• Suhu : Tidak dilakukan

STATUS PSIKIATRIKUS

Kesadaran: Compos
mentis Orientasi
Roman Muka: Baik Perhatian
• Tempat : baik
Kontak/ Rapport: • Waktu : baik • Mood: distimik
baik/adekuat • Orang : baik • Afek: luas
• Keserasian: afek
sesuai dengan mood
 STATUS PSIKIATRIKUS

• Remote: baik
• Past Recent: baik
• Recent: baik
• Halusinasi : (-)
• Recall: tidak ditanyakan a. Audio : Tidak ada kelainan
b. visual : Tidak ada kelainan
c. olfaktori : Tidak ada kelainan
d. gustatory : Tidak ada kelainan
Memori
e. tactile : Tidak ada kelainan
Persepsi• Ilusi: (-)
 STATUS PSIKIATRIKUS
• Bentuk: autistic
• Jalan: koheren
• Isi: waham hubungan (+), waham dosa (+),
thought insertion (+), thought withdrawal
(+), thought broadcasting (+), thought
TINGKAH LAKU
control (+), Suicide idea (+)
TILIKAN DEKOR
5
BICARA
UM

FIKIRAN BAIK
WAWASAN PENYAKIT ARTIKULASI DAPAT • Kebersihan: baik
DIMENGERTI,
SPONTAN. • Sopan santun:
baik
• Kooperatif: baik
 DIAGNOSIS MULTI AKSIAL
F32.3 Episode Depresif Berat dengan Gejala Psikotik
F25.1 gangguan Skizoafektif tipe defresif
F20 Skizofrenia
F31.5 Gangguanafektif bipolar, episode kini defresif
berat dengan gejala psikotik

AKSIS I

GAF scale 60-51 AKSIS V

AKSIS II
----

AKSIS IV AKSIS III

Masalah dengan “primary support
group” (keluarga), ----

dilarang berteman dengan

sahabatnya oleh ibunya
 MANAGEMENT
Mood stabilizer
R/ Asam Valproat tab 250 mg No.X
Anti Psikotik S 1 dd tab 1 0-0-1
R/ Aripiprazole tab 5 mg No.XXX Hipnotik dan
S 1 dd tab 1 0-0-1
sedatif
R/ Alprazolam tab 0,5 mg No.XXX
Antidepresan S 1 dd tab 1 0-0-1

R/ Sertraline tab 50 mg No.XXX

S 1 dd cap 1 0-0-1
PSIKOTERAPI

Psikoedukasi Psikoterapi
keluarga suportif
PROGNOSIS

• Quo ad vitam: ad bonam

• Quo ad functionam: dubia ad bonam
• Quo ad sanantionam: dubia ad bonam
Thank you
Ada pertanyaan?
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