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  بسماهللاالرحمنالرح  

STATUS UJIAN PSIKIATRI

DISUSUN OLEH :

Maharanny Wulansari

2008730022

PENGUJI :

Dr Ni Wayan Ani P! S"KJ

#AKU$TAS KED%KTERAN

UNI&ERSITAS MU'AMMADI(A' JAKARTA

I$MU KESE'ATAN JIWA

RUMA' SAKIT JIWA IS$AM K$ENDER 

20)3

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I IDENTITAS PASIEN

 Nama : Tn. AA

Jn!" #$am!n : La%!&$a%!

Tm'a()Tan**a$ $a+!, : U-n* 'an/an*0 12 3EI 2452

U"!a : 67 (a+n

A*ama : I"$am8n/!/!%an : S3A

S(a(" : 9$m mn!%a+

8%,-aan : 9$m 9%,-a

A$ama( : Ja$an Sman*"!+0 #a,(0 Ja%8"

Da(an* % ;ma+ Sa%!( : 26 S'(m, 7126

;!/!an*"a$?

  8a/a (an**a$ 76 S'(m, 7126 >/!an*"a$?

B A$$anamn"!" : 8a/a (an**a$ 77 S'(m, 7126 >%a%a% %an/n* 'a"!n C!a ($'n?

  8a/a (an**a$ 76 S'(m, 7126 >a/!% %an/n* 'a"!n C!a ($'n?

A K*luhan U+a,a

3n,( %a%a% %an/n*0 'a"!n "%a ma,a+&ma,a+ -!%a +a!" m$!+a( ""a(

=an* a/a /!/'an /!a0 %m/!an m$m'a, ""a( =an* a/a /!(an*an %a,a+

=an* /!a $!+a(0 $a$ 'a"!n ,!a,a n*a =an* (!/a% /! mn*,(! $+ ,an*

$a!n. 8a"!n "%a m,"a% a,an*&a,an* "',(! mman(!n* T0 mma+%an

%aa -n/$a0 mm%$ ,an* $a!n "a,a (!a&(!a0 /an 'a"!n "%a ($an-an*

/an $a,! %-a$anan.

- Ri.aya+ Gan//uan S*aran/

8a"!n m,'a%an '"( ,a

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mm%$ ,an* $a!n (an'a a/a "a0 m,"a% a,an*&a,an* "',(! mman(!n*

T0 mma+%an %aa0 mma+%an a,an*&a,an* =an* a/a /!,ma+ /an (!a&(!a

($an-an* /an $a,! %-a$anan. T(a'! /!"aa( 'a"!n (nan* /an !"a /!a-a% !a,a $+

%a%a%n=a0 %a%a%n=a ,(an=aan % 'a"!n0 %na'a %am m,"a% T0 /an 'a"!n

mn-a

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mm%$ ,an* $a!n (an'a "a. 8a"!n -*a "%a m,"a% a,an*&a,an* "',(!

mma(!n* (C0 mma+%an %aa -n/$a0 /an (!a&(!a ($an-an* /an $a,! %

 -a$anan. S+!n**a 'a"!n n(% ',(ama %a$!n=a /! a!mn%?.

4

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8a"!n -*a 'm!nm&m!nman ,a$%+$ =a!( -n!" !, +!(am /an m,%% >(!/a% 

/!%(a+! -m$a+n=a?.

6 Ri.aya+ M*i 

3n,( %a%a% /an a/!%n=a0 'a"!n 'a/a "!a (a+n >245M? 'a"!n ',na+

 -a(+ /a,! $an(a! 7 =an* (,a( /a,! %a=0 /an %a= !( a/a =an* $a'% %m/!an

(!/a% "n*a-a (,!n-a% $+ 'a"!n /an 'a"!n -a(+ "+!n**a (,n(, % %'a$a.

8a/a "aa( %-a/!an 'a"!n (!/a% a/a mn*$+ ma$0 mn(a+ a(a 'n,nan

%"a/a,an0 'a"!n +an=a mnan*!" /an (!/a% !"a !a,a "$ama 6 +a,!. 3n,(

%a%a% 'a"!n0 'a"!n "-a% !( "/!%!( $ama( ,!%!,0 "$!( n(% mma+am!

 '$a-a,an0 ((a'! /a$am "%$a+n=a (!/a% ',na+ (!n**a$ %$a". T(a'! mn,(

 'n*a%an 'a"!n0 'a"!n -a(+ /a,! $(. 7 %a,na /!-,%!n $+ "",an* =an* (!/a% 

(a+ "!a'a ,an*n=a.

8a"!n m,'a%an '"( ,a

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3n,( %a%a% 'a"!n0 'a"!n ',na+ -a(+ /a,! $(. 7 /!,ma+n=a 'a/a "!a

(a+n. S-a% !( 'a"!n (,$!+a( $ama( ,!%!,. S+a,!&+a,! 'a"!n ,"!a(

 'ma$ /!%$a,*an=a0 namn 'a"!n ((a' /a'a( ,!n(,a%"! /n*an

$!n*%n*an. 8a"!n ,*a$ a!% /n*an (man&(mann=a.

; Masa "u*r+as

'uun/an s4sial

3n,( %a%a% 'a"!n0 +n*an 'a"!n /n*an %$a,*an=a /%a( /an

(!/a% a/a ma"a$a+ /!%$a,*an=a0 (,(ama /n*an a=a+n=a =an* "%a

mman-a%an 'a"!n. Hn*an 'a"!n /n*an ,an* $a!n "',(! (man&

(man a(a ((an**a&((an**an=a a!%. 8a"!n (,ma"% (!' ,an* m/a+

 ,*a$0 "/!%!( 'ma$0 ((a'! (!/a% m/a+ !a,a0 -!%a !a,a +an=a =an*

 ',$&',$ "a-a.

 

Ri.aya+ "*niian 54r,al

3n,( %a%a%n=a0 'a"!n mn=$"a!%an /a,! SD "am'a! S3A /n*an

%mam'an =an* !a"a&!a"a "a-a. a$a'n /!a%! $+ %a%a%n=a (n(an*

!n($n*n"! =an* %,an* namn 'a"!n mam' mn=$"a!%an 'n/!/!%an

,ma$n=a.

• P*r*,an/an ,4+4ri an 4/ni+i5 

Da$am ',%man*an !"!%0 'a"!n (,$!+a( ""a! /n*an "!an=a /an /a$am

 ',%man*an %*n!(!n=a (!/a% (,$!+a( a/an=a *an**an.

 

Gan//uan *,4si an 5isi 

8a"!n ',na+ ,%$a+! /n*an an(a, %$m'% *an%n=a0 ((a'! +an=a

%a,na !%(&!%(an "a-a0 /an -!%a /! ,ma+ 'a"!n (,ma"% ana% =an*

 'ma$0 (!/a% an=a% !a,a /an !a,a "',$n=a.

 

Ri.aya+ "si4s*sual

8a"!n ',na+ 'aa,an ,a'a %a$! "ma"a S3A0 /an "aa( !n! 'a"!n

 $m mn!%a+ %a,na *an**an -!

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A+i>i+as s4sial

Smn-% ,an-a% /

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  I Mi,"i! hayalan! sis+*, "*nilaian

• 3!m'! : T!/a% a/a

•

#+a=a$an : T!/a% a/a

• S!"(m 'n!$a!an : 8n!$a!an (n(an* a!% /an ,%0 /!n!$a! : ,% 

o #(!%a /!(an=a -!%a mnm%an /m'( /! -a$an0 a'a%an /!am!$ a(a

/!%ma$!%an0 'a"!n mn-a

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. D,a$!"a"! : T!/a% a/a

D Pr4s*s Piir

2. 8,/%(!C!(a" : 3!"%!n !/

7. #n(!n!(a"

•  Blocking  : T!/a% a/a

• A""!a"! $n**a, : T!/a% a/a• In%+,n : A/a

• Word salad   : T!/a% a/a

•  N$*!"m : T!/a% a/a

•  Flight of idea : T!/a% a/a

E Isi Piiran

2. 8,%'a"! : T!/a% a/a

7. a+am :

a. 9!a, : T!/a% a/a

 . S!"(ma(!" : T!/a% a/a

. Sma(!% : T!/a% a/a/. 8a,an!/ :

& #-a,an : T!/a% a/a

& #"a,an : T!/a% a/a

& ;-%an : T!/a% a/a

& D!%n/a$!%an : T!/a% a/a

6. O""! : T!/a% a/a

. #m'$"! : T!/a% a/a

M. R!a : T!/a% a/a

? #un/si K4/ni+i5 an K*saaran

1. #"a/a,an : Composmentis7. O,!n(a"!

• a%( : #,an* a!% >8a"!n (!/a% /a'a( mn=(%an +a,!0 (an**a$0

  $an0 (a+n /an /a'a( mm/a%an "!an*)ma$am?

• Tm'a( : 9a!% >8a"!n (a+ /!,!n=a ,a/a /!mana /an /a'a(

mn=(%an a$ama( ;SJI #$n/,?

• O,an* : #,an* a!% >'a"!n %,an* mn*na$ (man

/!$!n*%n*ann=a "aa( !n!?

6. #n"n(,a"! : #,an* a!% >8a"!n (!/a% /a'a( m$a%%an 'n*,an*an

211&@ ((a'! !"a mn*-a M +, /a,! $a%an* =an*

"$mn=a /!($!" (,$!+ /a+$?. Da=a !n*a(

• Jan*%a 'an-an* : #,an* 9a!% >8a"!n (!/a% /a'a( mn*!n*a( nama

"a/a,a %an/n*n=a?

• Jan*%a "/an* : #,an* a!% >8a"!n (!/a% /a'a( mn*!n*a( %a'an

 'a"!n ma"% ,ma+ "a%!(?

• Jan*%a 'n/% : #,an* a!% >8a"!n (!/a% -!%a 'a"!n "/a+ "a,a'an?

• Jan*%a "*,a : 9a!% >8a"!n /a'a( mn*$an* mn=(%an (!*a nama

 n/a >'$'n0 'n"!$0 %? "($a+ '

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  -a,m -am /n*an a!%?

@. In($*n"!a /an 8n*(a+an Umm : 9a!% >8a"!n /a'a( mn=(%an

nama ',"!/n ;I "%a,an*?

7 Daya Nilai

2. 8n!$a!an ""!a$ : #,an* a!% >8a"!n %,an* ,""!a$!"a"! /n*an (man/!an*"a$n=a /an ,an**a'an (!/a% a/a =an* ma

 ,(man /n*ann=a?.

7. U-! /a=a n!$a! : #,an* a!% >3n,( 'a"!n0 -!%a /!a mnm%an /m'(

ma%a (!/a% ma mn*ma$!%ann=a0 %a,na !( "/a+ +a%

/!a?

8 RTA 9R*ali+y T*s+in/ 45 Aili+y

;TA (,*an**

@ Tilian

T!$!%an I : 8n=an*%a$an ((a$ (,+a/a' 'n=a%!(n=a

)0 Tara5 Da"a+ Di"*r6aya

T!/a% /a'a( /!',a=a

I& STATUS #ISIK 

a S+a+us In+*rna

#a/aan mm : Compos mentis

T%anan /a,a+ : 211)1 mmH*

S+ : 6051 

 Na/! : 47 )mn!(

;"'!,a"! : 76 )mn!(

#'a$a : N,m'+a$!0 ;am( +!(am0 /!"(,!"! m,a(a

3a(a : 8'!$ $a( !"%,0 (!/a% (am'a% %$a!nan

3$( : 9!!, (!/a% %,!n*0 "!an"!" &)&.

THT : Da$am a(a" n,ma$

L+, : #Q9 (!/a% (,aa0 (,a%a /!(n*a+0 (!,!/ (!/a% (,a"a mm"a, 

T,aK :

10

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8$m : "!%$,0 * )80 N*/a+i>*

Thy"i ' P4si+i>* ))?0 N*/a+i>*

Para+hy"hi 1' P4si+i>* 9)320 N*/a+i5  

&I IK'TISAR PENEMUAN (ANG -ERMAKNA

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3/ : H!'(!m

A% : Da(a, 

#",a"!an : T!/a% S,a"!

Qan*an ',"'"! : T!/a% A/a

8,"" '!%!, : 8,/%(!C!(a" m!"%!n !/

Qan**an !"! '!%!, : In%+,n

;TA : T,*an**

T!$!%an : D,a-a( I

&I #%RMU$ASI DIAGN%SIS

3n,( I%+(!"a, 8nman 9,ma%na /an 88DQJ&III0 %a"" !n! /!*$n*%an %

/a$am Gan//uan SiC4a5*+i5 +i"* h**5r*ni 9# 20  %a,na :

Asis I : SiC4a5*+i5 +i"* h**5r*ni 9# 20

• 3mn+! %,!(,!a mm /!a*n"!" "%!,n!a

• D!a*n"!" +,n!a n(% ',(ama %a$! +an=a /!(*a%%an 'a/a "!a ,ma-a

a(a /"$ "$ W a", "m!$$!n*0a(a $+ "!%a'0 (!n**! +a(! >$C(= mann,0 (,(a*,!ma"0 man,!"m0

12

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mn*!$! "a,a ,"n/a *,a >',an%"?0 %$+an +!' %n/,!a%a$0 /an n*%a'an %a(a

=an* /!$an*&$an* >!n(,a(! '+,a""?

8,"" '!%, mn*a$am! /!",an!"a"! /an 'm!a,aan (!/a% mnn( >,am$!n* ",(a

!n%+,n?.

Qan**an a%%(! /an /,n*an %+n/a%0 ",(a *an**an ',"" '!%, mmn=a

mnn-$. Ha$"!na"! /an /(a+ mn(?V

6. #,an* mam' mn*%"',"!%an % +an*a(an0 %$m(an a(a %ma,a+an ,an*

$a!nV

. Tam'a% n=a(a %(!/a%&'/$!an a!% (,+a/a' '-!an ma'n %amanV

M. #,an* (,(a,!% n(% mn*a$am! 'n*a$aman "%"a$ /n*an ,an* $a!n

>',+!(n*an "!a 'n/,!(a?V

. Ham'!, "$a$ mm!$!+ a%(!!(a" =an* /!$a%%an "n/!,!V

@. 8,%'a"! /n*an an(a"! /an !n(,"'%"! =an* ,$!+anV

5. T!/a% mm'n=a! (man /%a( a(a +n*an ',!a/! =an* a%,a >%a$a a/a +an=a

"a(? /an (!/a% a/a %!n*!nan n(% mn-a$!n +n*an "',(! !(V

4. San*a( (!/a% "n"!(! (,+a/a' n,ma /an %!a"aan ""!a$ =an* ,$a%.

• Un(% /!a*n"!" /!(+%an 'a$!n* "/!%!( 6 /a,! /!a(a".

Asis III :

& 8n=a%!( !n%"! (,(n( : T+=!/

Asis I& :

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Masalah *n/an *luar/a

8a"!n %,an* /!',+a(!%an $+ ,an*(an=a "-a% ,,a! /an %,an*n=a

%'/$!an %$a,*a (,+a/a' *an**an -!QAR? Sa$ @1&2

&III DA#TAR PR%-$EM

a. O,*an!$*!% : T!/a% a/a

 . 8"!%$*! : T!/a% a/a

. S"!a$) #$a,*a : 3a"a$a+ %$a,*a

I PR%GN%SIS

D!a

• Ra%(, & a%(, =an* mn/%n* % a,a+ ',*n"!" a!% :

o A/an=a "'',( %$a,*a =an* mn*!n*!n%an 'a"!n n(% "m+

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o 8a"!n %!n! m$a! ma m!nm a( "a,a (,a(, 

• Ra%(, & a%(, =an* mn/%n* % a,a+ ',*n"!" ,% :

o S!%a' 'a"!n =an* ma"!+ $m mn=a/a,! a+iu :

o 3m,!%an *ama,an %n(n*an !n/!C!/ -!%a mmanaa(%an

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o 3m,!%an "man*a( /an ma"%an '"!(! /an mn*a,a+%an 'a"!n

a*a, /a'a( ,"n**+ "n**+ mn-a/! man"!a =an* /!"nan*!

ma"=a,a%a(0 $(0 "'an /an ,',!$a% a!% 

T*ra"i +*rhaa" "r4l*, *luar/a :

o 3m,!%an na"!+a( %'a/a %$a,*a n(% ,"ama W "ama mman(

/an mn/%n* %"m+an a!% mn(a$0 -!