status psikiatrikus ukuran folio

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 :........................................................................................

Sebagai patokan dalam melakukan alloanamnesis, perhatikan petunjuk di bawah ini :1. Sebab utama membawa pasien ke Rumah Sakit Jiwa2. Keluhan utama pasien dalam serangan gangguan sekarang (yang didengar oleh

keluarga/sumber alloanamnesis)3. Riwayat perjalanan penyakit sekarang dan yang sebelumnya4. Riwayat dan gambaran kepribadian premorbid masa bayi, masa anak-anak, masa

remaja, dewasa, dan selanjutnya; gambaran ciri-ciri kepribadian premorbid5. Riwayat perkembangan organobiologik, penyakit-penyakit yang pernah diderita6. Riwayat pendidikan, pekerjaan, dan perkawinan7. Keadaan sosial ekonomi pasien atau orang tuanya8. 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

(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 : ............................................................................................................

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)

5. Keadaan Proses Berpikir

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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

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

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