kasus ujian psikiatri.reny jiwa bogor
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7/23/2019 KASUS Ujian PSIKIATRI.reny Jiwa Bogor
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KASUS PSIKIATRI
Penguji :
dr. Prasetiyawan, Sp.KJ
Pembimbing:
dr. Siti Khalimah, Sp.KJ
isusun !leh :
Reny Maulina
030.06.215
KEPANITERAAN KLINIK ILMU KESEHATAN JIWARUMAH SAKIT JIWA D. H. MAR!"EKI MAHDI
PERI"DE 1# JUNI 2013 $%& 2' JUNI 2013
(AKULTAS KED"KTERAN
UNI)ERSITAS TRISAKTI
JAKARTA2013
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STATUS PSIKIATRI
I. I"#TITAS Na*a + Tn. E
Jeni$ Kela*in + La,i-la,i
U*u + 2 /
Tanal Lai + 2 Ne*4e 1' u*u7
Aa*a + I$la*
Su,u 4an$a %8aa Neaa + Sun&a % In&ne$ia
S/a/u$ Peni,aan + 9elu* *eni,a
Pen&i&i,an Tea,i + SMA
Pe,e:aan + -
Ala*a/ + Keluaan Teal ;un&il Ke<a*a/an 9 U/aa
Tanal Ma$u, RS.MM + I;D /anal 26 Mei 2013
II. RI$A%AT PSIKIATRI
Au/ana*ne$i$ &i 4an$al ;a// Ka<a RSMM =a&a /anal 1' Juni &an 1 Juni 2013 &an
Allana*ne$i$ &enan an /ua =a$ien Tn.....> .../> =e,e:aan...7 &an I4u =$ien Ny....>
..../> ...7 $aa/ ,un:unan u*a =a&a /anal 20 Juni 2013. Dan &a/a &ai e,a* *e&i$
A. Keluhan Utama
Pa$ien *ena*u, &an *eu$a, 4aan-4aan $e:a, 3 :a* SMRS
&. Riwayat 'angguan Se(arang
Se:a, 10 4ulan yan lalu 2012> 2' /aun7 ,eluaa =a$ien *ena/a,an =a$ien *ulai
/elia/ $u,a *enyen&ii. Te/a=i =a$ien a:in un/u, *eni,u/i =ena:ian > ia *enye4u/nya $e4aai =a*e:anan a/au naa8iya /e*=a/ 4e,u*=ul &an *ena:i &i &aea /ana 4au. Pa$ien ?
Se:a, # 4ulan yan lalu 2012> 2' /aun7 *enuu/ ,eluaa =a$ien $ein ia /elia/
$ein 4i<aa $en&ii. Pa$ien *ena/a,an ia 4e4i<aa &enan 8ali $n &an *e*elu, $e/a
*enye*=/ 4in,ai 8ali $n &enan =e8ani =a,aian aa au*.
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Se:a, 4ulan yan lalu% SMRS (e4uai 2013> 2' /aun7 =a$ien *u&a /e$inun
&enan =e,a/aan *au=un =e4ua/an an lain /ea&a=nya> $ein *aa- *aa &an *eu$a,
ala/- ala/ u*a /ana $e=e/i *enen&an =in/u> *e*4uan =ea4/an &an *e*e<a,an ,a<a.
Pa$ien :ua *enala*i $uli/ /i&u ,aena *enuu/nya ia *en&ena $uaa =a, S9@ 4e4i<aa
,e=a&anya &enan *enu<a=,an /ei*a ,a$i ,aena /ela *en<4l$ ina =a, S9@ /e=ili
*en:a&i =e$i&en. Ke*u&ian =a$ien :ua *ena/a,an ia $ein *en&ena $uaa i4u-i4u $e&an
*en*en/ai &iinya.
Se:a, 3 *inu $e4elu* *a$u, u*a $a,i/ Mei 2013> 2' /aun7 =a$ien $ein ,eluyuan
/ena *ala* &an =ulan =a&a =ai ainya. Menuu/ =a$ien ia 4e:alan :alan *eni,u/i :e:a,
a$ul &enan &i/e*ani le Tuan. Pa$ien :ua /i&a, *au *a,an &an *inu* ,aena *ea$a /i&a,
la=a &an au$ $e/a /i&a, *au *ela,u,an =ea8a/an &ii $e=e/i *an&i> *enan/i 4a:u &an
*e*a,ai $an&al.
Se:a, 3 :a* $e4elu* *a$u, u*a $a,i/ 26 Mei 2013>2' /aun 7 =a$ien *aa *aa>
*eu$a, 4aan-4aan> *e*u,ul $ia=a $a:a yan *enalaninya &an inin *elu,ai ayanya
&enan =i$au. Pa$ien *ena/a,an ia *aa-*aa ,aena &i,en&ali,an le 8ali $n yan
*elia/ <aa $la/ ayanya yan $ala. Seina =a$ien &i4a8a le ,eluaa ayanya ,e I;D
u*a $a,i/ &.H. Mae,i Ma&i =a&a =u,ul 15.30 WI9 &enan ,ea&aan ,e&ua /anan &i i,a/.
Di I;D =a$ien &i=ei,$a le &,/e> &i/en/u,an &ian$i$ &an &i/a/a la,$ana &enan
*e*4ei,an $un/i,an &iae=a* 1 a*=ul &an al=ei&l 1 a*=ul un/u, *enenan,an =a$ien.
Sela*a 25 ai =ea8a/an> =a$ien *a$i *en&ena $uaa-$uaa. Pa$ien :ua *ena/a,an
4a8a ia *elia/ 4ayanan =u/i &an &a=a/ *en<iu* 4au a=i nea,a. Pa$ien $u&a /i&a, *aa-
*aa> *au *a,an &an *inu*> /e/a=i *a$i a&a ,e$uli/an $aa/ /i&u&an *a*=u *ea8a/ &ii.
Pa$ien $elalu *e*in/a un/u, =ulan ,aena *enuu/nya ia inin *ea8a/ 20 i$/inya &an 100
ana,nya. Pa$ien :ua $ein *elia/ 4ayanan i$/innya ia *ena/a,an i$/inya Bai4C
/e,a&an a&a /e/a=i /e,a&an /i&a, a&a.
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). Riwayat 'angguan Sebelumnya
1. Ri8aya/ P$i,ia/i Se4elu*nya
Se:a, 2 /aun yan lalu 2011> 2# /aun7 ,eluaa =a$ien *ena/a,an =eila,u =a$ien
*ulai 4eu4a $e:a, =a$ien &i 4een/i,an ,e:a &ai "ly*=i< $e/ela ,n/a, /ia /aun
4e$a*aan &enan 4ea,inya u4unan =a$ien &enan ,e,a$inya.Pa$ien *en:a&i $ein
4e&ia* &ii> /i&a, *au 4eaul &enan an lain>&an:aan 4e4i<aa.
Se:a, 4ulan ,e*u&ian2011> 2# /aun7 =a$ien $e*a,in $ein *enyen&ii &i &ala*
u*a> /i&a, =ena ,elua u*a> /i&a, *au *ela,u,an a=a-a=a &an *enin&a 4ila
4e/e*u an.
Se:a, 2 4ulan ,e*u&ian2011> 2# /aun7 =a$ien *en:a&i *u&a *aa> *u&a /e$ulu/
e*$i *u&a /e$inun a=a4ila &i*in/a /ln le an /ua =a$ien.Pa&a $aa/ *aa>
=a$ien $ein 4e/eia, /eia,> *eu$a, =eala/an u*a /ana>&an *enen&an =in/u.
Pa$ien ya,in 4a8a a&a $e$ua/u yan *enen&ali,an &iinya $eina *e*4ua/ =a$ien
*aa-*aa &an *eu$a, . Pa$ien *a$i 4i$a /i&u &an *a,an &enan 4ai,.Pa$ien &i4a8a
le an /ua =a$ien ,e 4e4ea=a =aan*al a,an /e/a=i /i&a, a&a =eu4aan ,eaa
=e4ai,an.
Se:a, (e4uai 2012 2# /aun7 =a$ien *enala*i $uli/ /i&u. Ji,a /i&a, 4i$a /i&u =a$ien
*en:a&i eli$a &an 4e:alan-:alan $en&ii ,elua u*a.Pa$ien *ena/a,an ala$annya
/i&a, 4i$a /i&u ,aena ia *en&ena $uaa 4anya, an yan $e&an *en4l /en/an
&iinya &an $ana/ *enanu. Te&a=a/ :ua $uaa yan *ena:a,nya 4e4i<aa.Suaa-
$uaa i/u /e&ena $e/ia= ai &an 4i$a /e&ena ,a=an $a:a.
Se:a, 3 ai 16 Mae/ 20127 $e4elu* *a$u, u*a $a,i/ =a$ien /i&a, *au *a,an &an
*inu*> /i&a, *au *an&i &an *ela,u,an a,/ii/a$ lain.
Se:a, 2 :a* $e4elu* *a$u, u*a $a,i/ 1 Mae/ 20127 > /i4a-/i4a =a$ien *ena*u,
$eina 4e/eia,> *eu$a, =in/u &an *enan<a* inin *e*4unu ayanya $eina
,eluaa =a$ien *e*u/u$,an un/u, *e*4a8a =a$ien ,e I;D u*a $a,i/ &.H. Mae,i
Ma&i. Pa$ien &i=ei,$a le &,/e &i4ei,an /ea=i un/u, *enenan,an =a$ien
,e*u&ian &i a8a/ &i uan Ke$na. Se/ela 3 ai =ea8a/an =a$ien $u&a /i&a, *aa-
*aa> $u&a *au *a,an &an *inu* $e/a *ea8a/ &ii.
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Pa&a /anal 2# *ae/ 2012 =a$ien &i=in&a,an ,e uan ;a// ,a<a &an =a&a /anal
13 A=il 2012 &i=in&a,an ,euan /enan @u&i$/ia. Pa&a =a$ien &ila,u,an /in&a,an ET
,nen$inal $e4anya, ,ali yai/u =a&a /anal # *ei> *ei > 11 *ei &an 1 *ei 2012.
Tia ai $e/ela ET ,nen$inal 1# *ei 20127 =a$ien &inya/a,an /enan &an
&i=ulan,an le &,/e un/u, a8a/ :alan &iu*a. Pa$ien &i4ei 4a/ un/u, a8a/ :alan
Hal=ei&l 3 5 *> l=*aine 1100 *> &an Tiey=eni&il 3 2 *. Pa$ien
=ulan &enan ,n&i$i yan $u&a *e*4ai,> /i&a, *en&ena $uaa-$uaa> &a=a/
4ea,/ii/a$> *au *a,an &an *inu* &an =ea8a/an &ii 4ai,.
Se/ela 2 4ulan =ulan ,eluaa *ena/a,an =a$ien /i&a, =ena 4e4i<aa $en&ii> *au
4e$$iali$a$i &enan /e/ana &an *ea8a/ &ii &enan 4ai,. Pa$ien :ua 4e,e:a $e4aai
=ea8ai &i u*a *a,an =a&an. Keluaa $ela*a ini *ena*4il 4a/ &i u*a $a,i/ &.
H.Mae,i Ma&i> &an an /ua a&ala =ena8a$ *inu* 4a/ &an *ea8a/ =a$ien
$ela*a &iu*a.
Kaena *a$ala 4iaya a/au n,$ ,e u*a $a,i/ ,eluaa =a$ien *e*u/u$,an un/u,
*ena*4il 4a/ &i =u$,e$*a$ &enan *e*in/a u:u,an &ai u*a $a,i/> a,an /e/a=i 4a/
&i=u$,e$*a$ /i&a, len,a= $eina =a$ien /i&a, *en&a=a/,an 4a/nya $e<aa /ea/u.
Sa/u 4ulan ,e*u&ian =a$ien /i&a, *au 4e,e:a lai> le4i $ein *enyen&ii &iu*a>
4e4i<aa $en&ii &an =e*4i<aaannya /i&a, &a=a/ &i*ene/i le ,eluaa.
5
2011 20132012
2011 Jun20
Mei 2013Mei 2012 (e4uai2012
2 4ulan =a$<a =ea8a/an
Dia8a/ &i RSMM $ela*a
,aena *ulai $ein *ena*u,>/i&a, *au *a,an &an
*inu*>/i&a, *au *ea8a/ &ii.
Pa$ien :ua *en&ena $uaa-
$uaa ,*en/a> *elia/ 4ayanan>*en<iu* 4au ane
&an *eya,ini &i,en&ali,an
8ali $n.Pa$ien &ia8a/ 3
4ulan>&i=ulan,an un/u, a8a/
:alan &enan ,n&i$i *e*4ai,&i4ei,an 4a/ P!>HP>THP
Di PHK
&ai =e,e:aan
&an =u/u$
&ai
,e,a$inya>Pa$ien
*ulai
*enyen&ii
&an
=en&ia*
Pa$ien ,e*4ali
&ia8a/ &iRSMM> ,aena
*ena*u,>*en
an<a*> &an
alu$ina$iau&i/i,>i$ual>
=e*4auan.
Pa$ien :ua
/e&a=a/ 8aa*
&i,en&ali,an.
Pa$ie
*a$i*en&
$ua
/e/a=
*au*a,a
*inu
&an
*ea
&ii
Pa$ien /i&a,
*inu* 4a//ea/u
>=a$ien
,e*4ali
*en&ena$uaa-$uaa>
$ein
*ena*u,>
&an 4een/i
4e,e:a
Pa$ien $u&a
/i&a,*en&ena
$uaa-$uaa>
/i&a, *aa-
*aa. Pa$ien*ulai 4eaul
&enan
/e/ana &an
4e,e:a &i
u*a *a,an =a&an
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2. Ri8aya/ Penya,i/ Me&i$ Lainnya
Pa$ien /i&a, =ena &ia8a/ &iu*a $a,i/ ,aena =enya,i/ *e&i$ lainnya> /i&a,
=ena =ea$i &an /i&a, =ena *enala*i ,e<ela,aan.
3. Ri8aya/ Penunaan !a/ P$i,a,/iF &an Al,l
Pa$ien *ena,u /i&a, =ena *enuna,an na,4a &an *inu* al,l> /e/a=i
=a$ien $ein *en,n$u*$i ,=i &an *e,,.
. Riwayat Kehidupan Pribadi
1. Ri8aya/ =ena/al &an =eina/al
Wa,/u &i,an&un $ lai n*al> <u,u= 4ulan> /i&a, =ena *enala*i ,e:an. Ti&a,
a&a *a$ala ,e$ea/an Fi$i, *au=un e*$inal i4u $ela*a a*il.
2. Ma$a Kana, A8al 0 - 3 /aun7
• Pa$ien /eln ana, yan $ea/.
• Pa$ien &ia$u le i4unya &iu*a> &enan *a$a *enyu$ui $a*=ai u$ia 4ulan.
• Pa$ien &e,a/ &enan i4u &an 4a=a,nya.
• Pa$ien 4i$a 4e:alan $e,i/a u*u 1>5 /aun> /i&a, a&a ,e/ela*4a/an 4i<aa /e/a=i
an /ua =a$ien lu=a ,a=an =a$ien *ulai 4i$a 4e4i<aa.
• Pa$ien /i&a, /e&a=a/ anuan =la /i&u
• Pa$ien /i&a, =ena *en*=l &an i4u =a$ien *ena:a,antoilet training
• Pa$ien aa, =e*alu 4ila 4e/e*u &enan an yan /i&a, &i,enalnya
• Pa$ien /i&a, =ena *aa-*aa 4ila ,eininannya /i&a, &i=enui> /i&a, =ena
*en:a/u,an 4a&an> *e*4en/u,an ,e=ala &an 4eulin.
• Pa$ien le4i $u,a 4e*ain $en&ii &i4an&in,an 4e*ain &enan /e*an-/e*an
$e4ayanya.
3. Ma$a Kana, Pe/enaan 3 - 11 /aun7
• Pa$ien =e*alu &an ,uan $u,a 4e*ain 4e$a*a /e*an-/e*annya
• Pa$ien /i&a, $u,a 4e,elai &an /e*a$u, ana, yan =enuu/
• Pa$ien 4u,an /e*a$u, ana, yan ==ule &i $e,la
• Pa$ien /i&a, $u,a *enyi,$a 4ina/an
• Pe$/a$i =a$ien /e*a$u, a/a-a/a &i$e,la
• Pa$ien /i&a, *e*ili,i =eila,u *enya,i/i &ii $en&ii &an 4e*ain a=i
. Ma$a Kana, A,i =u4e/a$ &an e*a:a7
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a. Hu4unan S$ial
• Keluaa =a$ien *ena/a,an =a$ien ,uan *e*ili,i 4anya, /e*an> =a$ien
le4i $u,a *enyen&ii &an /i&a, $u,a *ela,u,an ,eia/an &ilua u*a
• Pa$ien ,uan $u,a 4e*ain 4la a/au laaa lainnya &enan /e*annya
4. Ri8aya/ Pen&i&i,an
Lulu$ SD 6 /aun>SMP 3 /aun> &an Lulu$ SMA 3 /aun.Pa$ien /i&a, =ena /inal
,ela$&enan =e$/a$i a/a a/a.
<. La/a 9ela,an Aa*a
Pa$ien 4eaa*a i$la* &an ,eluaa *ena/a,an =a$ien/aa/ 4ei4a&a
5. Ma$a &e8a$a
a. Ri8aya/ Pe,e:aan
Pa$ien =ena 4e,e:a &i /, Funi/ue "ly*=i< $e4aai =ea/ *e$in =/n =a=an
$ela*a 3 /aun 200'-20117 ,e*u&ian a4i$ ,n/a,.Pa$ien /i&a, *elan:u/,an
4e,e:a &i "ly*=i< ,aena /e:a&i =enuanan ,aya8an.Se/ela =ea8a/an yan
=e/a*a 20127 &i u*a $a,i/ &an ,elua un/u, a8a/ :alan =a$ien =ena 4e,e:a &i
u*a *a,an =a&an $ela*a ,uan le4i $a/u 4ulan &an 4een/i 4e,e:a ,aena
=a$ien *ea$a ,elelaan au$ *enan,a/ lau, =au, yan 4ea/ &enan :aa, 500
*e/e &ai &a=u ,e u*a *a,an =a&an $e<aa 4eulan. Se/ela i/u =a$ien 4een/i
4e,e:a.
4. A,/ii/a$ S$ial
Pa$ien /inal &i u*a 4e$a*a an /uanya &an a&i,-a&i,nya.Pa$ien :aan
*ela,u,an ,eia/an $$ial &i lin,unan u*anya $elain *enya=a /e/ana
&e,a/nya.
<. Ri8aya/ P$i,$e,$ual
• Pa$ien =ena :a/u a/i &an *an:alani u4unan &enan $ean 8ani/a
• Pa$ien 4elu* *eni,a
". situasi (ehidupan se(arang
Pa$ien *eu=a,an ana, =e/a*a &ai &ela=an 4e$au&aa.Se:a, lai =a$ien &ia$u le
,e&ua an /uanya.Sela*a ini ,euanan ,eluaa &i/anun le aya =a$ien yan 4e,e:a
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$e4aai /u,an :e.Se:a, /aun 2010 aya =a$ien 4een/i 4e,e:a $e4aai /u,an :e
,aena *ea$a /elalu lela. Se:a, i/u aya =a$ien 4e,e:a $ea4u/an &an anya 4e,e:a 4ila
a&a /e/ana yan *e*elu,an /enaanya.I4u =a$ien /i&a, 4e,e:a.A&i,-a&i, =a$ien *a$i
$e,la &i4an,u SMA> SMP &an SD. Di ,eluaanya /i&a, a&a yan *enala*i =enya,i/
$eu=a &enan =a$ien.
*. Impian,*antasi,nilai nilai
Pa$ien/i&a, *e*=unyai <i/a <i/a /e/en/u> ia anya inin 4e,e:a *e*4iayai an /ua &an
*eni,a.
P++# K"-UAR'A
Ke/eanan +
+ + =ia + 8ani/a
+ Tinal Seu*a + Menala*i anuan :i8a
+ Pa$ien
II. STATUS "#TA-
ila(u(an pada tanggal /0 dan /1 Juni 23/4 di bangsal'at!t Ka5a RS
A. es(ripsi Umum
'
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1. Ke$a&aan
*=$ *en/i$> 3 P a&e,ua/
2. Pena*=ilan U*u*
Seanla,i-la,i 4eu*u $e,i/a 2 /aun> 4e=ena*=ilan Fi$i, /elia/ $e$uai
&enan u$ianya> ,uli/ ,unin lan$a/> a*4u/ =en&e, 4e8ana i/a*> /a*=a, /enan.
Pa,aian <u,u= a=i &an /i&a, /elia/ lu$u> /i&a, *e*a,ai ala$ ,a,i.
4. Peila,u &an A,/ii/a$ M/i,
• Se4elu* 8a8an<aa =a$ien $e&an &u&u, &i ,u$i
• Sela*a 8a8an<aa> =a$ien/enan> =a$ien 4i<aa $e=elunya> a&a ,n/a,
*a/a&enan =e*ei,$a> =ea/ian *u&a /eali. Sela*a 8a8an<aa
=a$ien ,=ea/iF &ala* *en:a8a4 =e/anyaan> /i&a, /elia/ ,a,u> &an
/a*=a, nya*an.
• Se/ela 8a8an<aa =a$ien ,e ,a*a un/u, /i&u
. Pe*4i<aaan
Pa$ien *en:a8a4 =e/anyaan yan &ia:u,an &enan a/i,ula$i yan:ela$> $uaa
$e&an> lan<a &an $=n/an &ala* *en:a8a4 =e/anyaan.
5. Si,a= Tea&a= Pe*ei,$a + ,=ea/iF
&. Alam Perasaan
1. M& + Ii/a4el
2. AFe, + Te4a/a$
3. E,$=e$i aFe,/iF
a. Ke$/a4ilan + Ti&a, $/a4il 4. Ke$unuan + E</
<. Ke$ea$ian +Sea$i&. Penen&alian + u,u=e. E*=a/i + Da=a/ &ia4a a$a,an
). *ungsi Intele(tual
1. TaaF =en&i&i,an> =ene/auan &an ,e<e&a$an+
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TaaF Pen&i&i,an + Se$uai &enan /aaF =en&i&i,an
Pene/auan U*u* + 9ai,. Pa$ien *a*=u *en<ei/a,an *a$ala =li/i, $aa/ ini
Ke<e&a$an +9ai,. =a$ien *a*=u *en,ali &an *e*4ai an,a-an,a
2. Daya ,n$en/a$i+
Kuan. Pa$ien /i&a, 4i$a 4ei/un *un&u 100-#
3. "ien/a$i +
Daya "ien/a$i Wa,/u+ 9ai,. Pa$ien &a=a/ *ene/aui$ian a/au *ala*> :a*> ai &an
/anal
Daya "ien/a$i Te*=a/ + 9ai,. Pa$ien *ene/aui &iinya 4ea&a &i Ru*a Sa,i/
Daya "ien/a$i Pe$nal + 9ai,. Pa$ien *ene/aui $ia=a yan *e*ei,$anya
. Daya ina/+
Daya Ina/ Jan,a Pan:an + 9ai,. Pa$ien *a$i ina/ na*a $e,la SD-nya
Daya Ina/ Jan,a Pen&e, + 9ai,. Pa$ien *a$i *enina/ *enu $aa=an /a&i =ai
Daya Ina/ Se$aa/ + 9ai,. Pa$ien *a*=u *enu<a=,an ,e*4ali a=a yan
$u&a ia <ei/a,an $e4elu*nya
5. Pi,ian A4$/a, + 9ai,. Pa$ien *a*=u *enya*a,an
2 4:e, $e=e/i eli,=/e &enan =e$a8a/. Pa$ien
*ena/a,an ,e&uanya 4i$a /e4an
6. Ke*a*=uan Menln Dii + 9ai,. Pa$ien *a*=u *a,an &an *an&i $en&ii
. 'angguan Persepsi
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1. Halu$ina$i +Halu$ina$i au&i/i, G7 Pa$ien *en&ena 4i$i,an yan *ena:a,nya
4e4i<aa a/au $e,el*=, an yan $e&an *e*4i<aa,an &iinya.
Halu$ina$i i$ual G7 Pa$ien *elia/ a&a 4ayanan =u/i
Halu$ina$i =e*4auan G7 Pa$ien *en<iu* 4au a=i nea,a
Ilu$i + Ti&a, a&a
2. De=e$nali$a$i + /i&a, a&a
Deeali$a$i + /i&a, a&a
". Pr!ses Pi(ir
1. Au$ Pi,i
P&u,/ii/a$ + Pa$ien 4e4i<aa $e<aa $=n/an &an lan<a
Kn/inui/a$ Pi,ian + Ja8a4an =a$ien $e$uai &enan =e/anyaan>/eaa ,e/u:uan
&an elean
Hen&aya 9e4aa$a + Ti&a, a&a. Pa$ien /i&a, *enuna,an 4aa$a yan /i&a,
&i*ene/i%,a/a ,a/a 4au yan anya =a$ien *ene/i
neli$*e7 a/au =a$ien *enuna,an 4aa$a $e<aa lai*
$e$uai &enan /a/a 4aa$a
2. I$i Pi,i
Pe,u=a$i + Ti&a, a&a
Waa* + Waa* &i,en&ali,an (delusion of control)Pa$ien ya,in
4a8a &i,en&ali,an le 8ali $n.
Waa* Ke4e$aan> =a$ien ya,in &e,a/ &enan 4a=a,
S9@> &e,a/ &enan a$ul &an Tuan> Me*=unyai i$/i 20
&an ana, 100
Waa* ,eaa*aan
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*. Pengendalian Impuls
u,u= 4ai,. Sela*a 8a8an<aa =a$ien /enan.
'. aya #ilai
1. Daya nilai $$ial
9ai,. ,e/i,a &i4ei =e/anyaan *enenai a=a,a *aa-*aa =a&a an /ua i/u 4ai,
a/au /i&a,> =a$ien *en:a8a4 al /e$e4u/ /i&a, 4ai,
2. U:i &aya nilai
9ai,. Ia *ena/a,an a=a4ila *ene*u,an &*=e/ yan /e:a/u a,an &i,e*4ali,an
,e=e*ili,nya
3. Penilaian eali/a
Teanu> ,aena /e&a=a/ alu$ina$i au&i/i,.
. Tili(an : Dea:a/ I
Pa$ien /i&a, *ea$a 4a8a &iinya $a,i/% *enala*i
anuan :i8a.
I. Tara6 apat iper5aya : Da=a/ &i=e<aya
I7. STATUS *ISIK
Pemeri(saan 6isi( dila(u(an tanggal /1 Juni 23/4 pada pu(ul 31:33 wib
A. Status Internus
Kea&aan u*u* + 9ai, Ke$a&aan + K*=$ *en/i$
Te,anan &aa + 120%'0 **H
(e,uen$i na=a$ + 20%*eni/(e,uen$i na&i + '%*eni/
Suu + AFe4i$
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S/a/u$ ii + Ke$an ii <u,u=n*al7
T9 163 <* 99 # ,+ IMT 22>6
Kuli/ + Kunin lan$a/Ke=ala + Ti&a, a&a &eF*i/a$
Ra*4u/ + Hi/a*> luu$> =en&e, Ma/a + Kn:un/ia /i&a, =u<a/> $,lea /i&a, i,/ei,
THT + Dala* 4a/a$ n*al
;ii &an *ulu/ + Dala* 4a/a$ n*alLee + Pe*4e$aan K;9 -7
Ta,$
Jan/un + 9unyi :an/un I-II n*al> *u*u -7> all= -7
Pau + Si*e/i$> e$i,ule> -%-> 8-%-Ta*=a, 4e,a$ lu,a 4a,a =a&a /a,$ $e4ela ,anan &enan
u,uan #5 <*A4&*en + Da/a> $u=el> 4i$in u$u$ n*al> e=a/*eali -7
E,$/e*i/a$ + A,al ana/> e&e*a -7Ta*=a, lu,a 4e,a$ $un&u/ ,, &i ,e&ua lenan.
&. Status #eur!l!gis
;S + 15 E>)5>M67
Ka,u ,u&u, + -7
Pu=il + 9ula/> i$,>eFle,$ <aaya lan$un G7
Ke$an =aa$e neu$ ,aniali$ + -7
M/i, + Ke,ua/an 57> /nu$ 4ai,> ii&i/a$ -7> $=a$*e -7> i=/ni
-7> eu/Fi> /i&a, a&a anuan ,e$ei*4anan &an
,&ina$i
Sen$i, + Ti&a, a&a anuan $en$i4ili/a$
ReFle Fi$ili$ + N*al
ReFle =a/li$ + -7
;e:ala e,$/a=ia*i&al + -7
;aya 4e:alan &an =$/u /u4u + N*al
S/a4ili/a$ =$/u /u4u + N*al
Te* &i ,e&ua /anan + -7
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7. IKTISAR P"#"UA# &"RAK#A
Pa$ien la,i-la,i u$ia 2 /aun> &i4a8a le ,eluaanya &enan ,eluan $ein *aa-
*aa &an *ena*u,. Pa$ien *ea$a ya,in :i8anya ,$n &an $e=e/i &i,en&ali,an $e$ua/u.
,aena =a$ien *ea$a ,e$al &an /eanu ,aena *en&ena $uaa-$uaa> *elia/ 4ayanan
=u/i &an *en<iu* 4au a=i nea,a. Pa$ien :ua $u&a ,uan naF$u *a,an &an /i&a, *au
*ea8a/ &ii =a&a $aa/ &i4a8a ,e RS.
Ke$a&aan =a$ien <*=$ *en/i$> ala* =i,ian> =ea$aan &an =e4ua/an /eanu.
Pa$ien 4e=ena*=ilan Fi$i, $e$uai &enan u$ianya> ,uli/ ,unin lan$a/> ,ea=ian &an
,e4e$ian <u,u=. Te&a=a/ alu$ina$i au&i/i,> alu$ina$i i$ual> &an 8aa* &i,en&ali,an.
Daya nilai eali/a /eanu ,aena a&anya 8aa* &an alu$ina$i. Tili,an &ea:a/ 1 &an $e<aa
,e$eluuan &a=a/ &i=e<aya.9e&a$a,an =e*ei,$aan Fi$i, /i&a, /e&a=a/ ,elainan ,n&i$i
*e&i, lain.
7I. *+RU-ASI IA'#+STIK
iagn!sis A(sis I : S(i8!6renia paran!id
9e&a$a,an ana*ne$i$> =a$ien /i&a, *e*ili,i i8aya/ <e&ea ,e=ala> i8aya/ /in&a,an
=ea/iF> &an i8aya/ ,n&i$i *e&i, lain yan &a=a/ $e<aa lan$un a/au=un /i&a, lan$un
*e*=enaui Fun$i /a,. 9e&a$a,an =e*ei,$aan Fi$i, :ua /i&a, &i/e*u,an ,n&i$i
*e&i$ u*u* yan &a=a/ *e*=enaui Fun$i /a,.Pa$ien /i&a, *enala*i anuan yan
4e*a,na yan *eni*4ul,an anuan :i8a."le ,aena i/u> anuan *en/al ani, (00-
07 &a=a/ &i$in,i,an.
Pa&a =a$ien /i&a, &i/e*u,an i8aya/ =enunaan 4a/%a/ =$i,a,/iF.Seina &ian$i$
anuan *en/al &an =eila,u a,i4a/ =enunaan a/ =$i,a,/iF (10-17 &a=a/ &i$in,i,an.Pa&a =a$ien /e&a=a/ e:ala-e:ala =$i,/i, $e=e/i 4i<aa ,a<au> *aa-*aa> $uli/ /i&u>
alu$ina$i au&i/i, &an 8aa* &i,en&ali,an &elu$in F <n/l7 . Pa$ien $u&a *enun:u,an
e:ala =eu4aan =eila,u $e=e/i *enai, &ii /ea&a= lin,unan> le4i $u,a 4e&ia* &ii
&i,a*a &an :aan 4e,*uni,a$i &enan ,eluaanya $en&ii $e:a, 2 /aun yan lalu. Dai
e:ala &an /an&a &ia/a$> &ian$i$ le4i &i4ea/,an =a&a (.20.0 yai/u anuan $,iFenia
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=aani& 4e&a$a,an PPD;J-III> &i*ana =a&a i8aya/ =enya,i/ $e,aan /e&a=a/ e:ala &an
/an&a $e=e/i> alu$ina$i au&i/i, 4en/u, e4al4eu=a $uaa-$uaa &ai an
/e/en/u>alu$ina$i =e*4auan> alu$ina$i i$ual > anuan i$i =i,i 4eu=a 8aa*
&i,en&ali,an> &ala* 8a,/u le4i &ai 1 4ulan &an /ili,an &ea:a/ I.
iagn!sis a(sis II :
9e&a$a,an ana*ne$i$ yan &ila,u,an /e&a=a/ <ii ,e=i4a&ian $,ii& ,aena /i&a,
*e*ili,i *ina/ *au=un *eni,*a/i u4unan &e,a/ /e*a$u, *en:a&i 4aian &ai ,eluaa>
a*=i $elalu *e*ili a,/ii/a$ $ean &ii> /i&a, *e*ili,i $aa4a/ a/au an yan
&i=e<aya $elain $ana, $au&aa &ea:a/ =e/a*a> *enun:u,,an e*$i yan &inin> =ele=a$an
a/au =en&a/aan eFe,/ii/a$.
iagn!sis a(sis III :
Pa&a =e*ei,$aan Fi$i, &an neuli$ /i&a, &i/e*u,an ,n&i$i *e&i, yan 4eu4unan
&enan ,n&i$i =a$ien =a&a $aa/ ini> &a=a/ &i$i*=ul,an 4elu* a&a &ian$i$ =a&a a,$i$ III
iagn!sis a(sis I7
Ma$ala &enan ,eluaa + Ti&a, a&a. Pa$ien /i&a, *e*ili,i
*a$ala a/au=un =e$eli$ian
/ea&a= ,eluaanya
Ma$ala &enan lin,unan $$ial + Ti&a, a&a. Pa$ien /eu $a=a &enan /e/ana
Ma$ala =en&i&i,an + Ti&a, a&a. Pa$ien lulu$ SD>SMP>SMA
Ma$ala =e,e:aan + A&a. Pa$ien &i PHK
Ma$ala e,n*i + A&a. Pa$ien /e*a$u, *a$yaa,a/
&enan e,n*i ,uan> &i*ana 4a=a,
=a$ien anya $ean /u,an
:e
Ma$ala a,$e$ ,e =elayanan ,e$ea/an +Ti&a, a&a. Ru*a =a$ien /i&a,
/elalu :au &ai RS &an
*a$i 4i$a &i:an,au
&enan ,en&aaan u*u*
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iagn!sis a(sis 7
S,ala ;A( +
'A* -P% + #0-61
4e4ea=a e:ala inan &an *ene/a=> &i$a4ili/a$ inan
&ala* Fun$i $e<aa u*u* *a$i 4ai,7
(un$i P$i,li$ +=a$ien /e&a=a/ alu$ina$i G> 8aa* G(un$i $$ial +=a$ien *a$i 4e,*uni,a$i &an 4ein/ea,$i &enan
,eluaa &an lin,unan $e,i/a> /e/a=i <en&eun
*enyen&ii
(un$i =ea8a/an &ii + =a$ien *a$i &a=a/ *ea8a/ &iinya $en&ii
'A* )urrent + 60-51
;e:ala $e&an M&ea/e7> &i$a4ili/a$ $e&an 7(un$i =$i,li + =a$ien alu$ina$i G> 8aa* G
(un$i $$ial +=a$ien *enala*i anuan &ala* u4unan &enan
eali/a
(un$i =ea8a/an &ii + =a$ien ,uan *ea8a/ &iinya $en&ii
7II. "7A-UASI U-TIAKSIA-
A,$i$ I + S,iFenia =aani&
A,$i$ II +ii ,e=i4a&ian $,ii&
A,$i$ III + Ti&a, a&a &ian$i$
A,$i$ I) + Ma$ala =e,e:aan &an e,n*i
A,$i$ ) + ;A( HLP@ + #0-61
;A( uen/ + 60-51
7III. A*TAR PR+&-"
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"an4ili$ + Ti&a, /e&a=a/ Fa,/ ee&i/e
P$i,li$+ Halu$ina$i au&i/i,> alu$ina$i =e*4auan> alu$ina$i i$ual &an 8aa*
&i,en&ali,an
S$i4u&aya + Hen&aya &ala* Fun$i $$ial
I9.PR+'#+SIS
A& i/a* + A& 4na*
A& Fun/ina* + Du4ia a& 4na*
A& $ana/ina* + Du4ia a& 4na*
A. (a,/ yan *e*=einan+
• Ti&a, /e&a=a/ Fa,/ ee&i/e
• Di,e/auinya Fa,/ =en<e/u$ /i*4ulnya anuan yai/u ilannya =e,e:aan &an =u/u$
u4unan &enan ,e,a$i
• Kn&i$i =a$ien yan $e<aa u*u* *a$i 4ai, &an ,e*a*=uan *ea8a/ &ii $en&ii
*a$i 4ai,
• Keluaa yan $ana/ *enyayani =a$ien &an *en&u,un =en4a/an =a$ien
• Lin,unan $e,i/a *enei*a ,e4ea&aan =a$ien yan *e*ili,i anuan :i8a
• Pa$ien =ena 4e,e:a $e4elu*nya
9. (a,/ yan *e*=e4ea/+
• Ma$ala =ee,n*ian ,eluaa =a$ien
• Se,aan =a$ien /i&a, 4e,e:a
9. P"#ATA-AKSA#AA#
• P$i,Fa*a,a
Ri$=ei&ne 22*%ai
Hal=ei&l 35 *%ai
S$i/ea=i
Pasien:
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Ai$ I+
• Pa$ien &i4ei,an ,e$e*=a/an $elua$-lua$nya un/u, *enun,a=,an i$i a/inya a/au
=e*a$alaan yan $e&an &ia&a=inya> $eina =a$ien le4i *ea$a /enan &an 4ea/i.
• Me*4ei,an =$i,/ea=i $u=/iF &enan *e*/ia$i =a$ien un/u, /eu$ *inu* 4a/
/ea/u> *e*ili,i $e*ana/ un/u, $e*4u> *e*4ei,an &u,unan /ea&a= al =$i/iF
yan &ila,u,an =a$ien.
Me*4ei,an =$i,/ea=i Ree&u,a/iF yai/u *e*4ei,an e&u,a$i &an inF*a$i /en/an
=enya,i/ yan &i&ei/anya> yai/u e:ala> &a*=a,> Fa,/ =enye4a4> <aa =en4a/an>
=n$i$ &an ,e,a*4uan. Selain i/u> au$ &i:ela$,an =ula 4a8a =en4a/an a,an
4elan$un la*a> a&anya eFe, $a*=in 4a/ &an =ena/uan &$i$ 4a/ anya 4le
&ia/u le &,/e.
Ai$ II +
• Mela,u,an Tea=i A,/ii/a$ Kel*=, unu/, *enin,a/,an $$iali$a$i &an
,e/ea*=ilan
Ai$ III + -
Ai$ I) +
• Rea4 =$i,$$ialun/u, *e*4ei,an =ela/ian *ea8a/ &ii &an ,e/ea*=ilan un/u,
=e$ia=an =ulan ,e*4ali%
• Kn/l ,e =u$,e$*a$ 4ila :aa, ,e u*a $a,i/ :au a/au 4iaya le4i 4e$a> un/u,
*en&a=a/,an 4a/ $e<aa /ea/u &an *inu* 4a/ $e<aa &i$i=lin
• Men<ai $i$/e* $u*4e un/u, =a$ien una *en&a=a/,an =e,e:aan 4au yan $e$uai
Ai$ ) +
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• Me*4an/u &an *enean,an ,e=a&a =a$ien /en/an iieni/a$ &an =ea8a/an &ii yan
4ai,
Keluarga:
-Me*4ei e&u,a$i,e=a&a ,eluaa =a$ien aa $elalu *e*4ei &u,unan
,e=a&a =a$ien- Menina/,an ,eluaa un/u, *e*4a8a =a$ien ,n/l ,e RS &an*enn/l
=a$ien un/u, *inu* 4a/ $e<aa /ea/u
- Me*4ei,an e&u,a$i =en/innya a,/ii/a$ daily living &ala* ,ei&u=annya
$eai-ai ,aena 4i$a *enalia,an =ea/iaan =a$ien ,e=a&a al al yan
=$i/iF
- Me*4ei,an ,e$e*=a/an ,e=a&a =a$ien un/u, i,u/ 4e,e:a ,e*4ali 4e$a*a
,a,a,nya $eina =a$ien *ea$a 4euna &an &a=a/ *e*4ei,an a$a =e<aya &ii &ala* &ii =a$ien 4a8a ia *a*=u un/u, 4eFun$i $e<aa n*al
1