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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
2014

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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

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

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 perluperlu 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)

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)
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