case jiwa dw tn z

7/25/2019 Case Jiwa DW Tn Z

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Yolanda Theresia Sanjaya (406147038)

DAFTAR ISI

HALAMAN DEPAN

DAFTAR ISI..........................................................................................................................

1

I. IDENTITAS PASIEN................................................................................................

2

II. STATUS PSIKIATRI.................................................................................................

3

III. PEMERIKSAAN STATUS MENTAL......................................................................

10

IV. PEMERIKSAAN DIAGNOSTIK LEBIH LANJUT.................................................

16

V. PEMERIKSAAN LABORATORIUM......................................................................

18

VI. IKHTISAR PENEMUAN BERMAKNA..................................................................

19

VII. DIAGNOSIS..............................................................................................................

20

VIII. EVALUASI MULTI AXIAL......................................................................................

23

IX. FORMULASI TERAPI.............................................................................................

23

X. PROGNOSIS.............................................................................................................

24XI. LAMPIRAN...............................................................................................................

2

Fakultas Kedokteran Uniersitas Taru!ana"araKe#aniteraan Klinik $l!u Kesehatan %i&a'eriode 0 ei * 04 %uni 016

1


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I. IDENTITAS PASIEN

N!. R"#$% M"&'( ) AAA.BBB

T$*++$, M$(-# R-%$ S$#'/ ) A+-(/-( 2013

K",$( P"$$/$* ) III

D!#/" $*+ %"$$/ ) &. E. S. KJ

R'$$/ P"$$/$* ) P"$$/$* #" I

N$%$ ) T*. 5

J"*'( K",$%'* ) L$#' ,$#'

U%- ) 4 /$-*

T"%$/ 7 T$*++$, L$' ) J$#$/$ 22 O#/!" 1968

B$*+($ 7 S-#- ) I*&!*"('$ 7 T'!*+!$

A+$%$ ) K$/!,'#

S/$/-( P"*'#$$* ) B",-% %"*'#$

A,$%$/ ) :"*+#$"*+

P"*&'&'#$* /"$#' ) S1 '&$*+ A#-*/$*(' &' U*';"('/$( T'($#/'

P"#"


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II. STATUS PSIKIATRI

D'"!," &$')

1. A-/!$*$%*"('( =$$*>$$?) &'&$$/ &$' $('"*.

2. A,,!$*$%*"('( &'"!," &$' medical record$('"* &$* $,,!$*$%*"($ &"*+$*

"$$/ &' S$*$/!'-% D$%$$*+($.

N$%$ ) T*. P

J"*'( K",$%'* ) L$#' ,$#'

U%- ) 4 /$-*

P"#"$$ %"*+$*+#$/ /$*+$* &$*


3


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%"*'-% $- %'*$#

$*+' $$ /"$/-. K"("$'$* $('"*

$*$# &'$'(#$* &'#$%$ $/$- &-&-# &'$*+#- &"$* #$%$*$ ($%',

%"!#!# $/$- %'*-% #!'. P$('"*


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%"%-/-(#$* -*/-# %"%$$*$ -,$*+. P$&$ /$-* 2009 ($%$'

2012 $('"* #",-$ &$' S$*$/!'-% D$%$


6/36


Suunan angg!ta keluarga

K"/"$*+$* )

,$#',$#'

""%-$*

$('"* "*+'&$ #",$'*$* #"


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2. N$%$ ) N. B

P"#"


8/36


H--*+$* &"*+$* $('"* ) A&'# #$*&-*+ "/$%$

8. N$%$ ) C@

P"#"


9/36


''. R'$$/ P"#"'&"$ #$"*$

#"+'$/$* %','/".

;. R'$$/ K"$+$%$$*

P$('"* "$+$%$ K$/!,'# &$* -/'* #" +""


10/36


;''. S'/-$(' H'&- T"#'*'

P$('"* %$%- %"*&"(#'('#$* /"%$/ /'*++$,*$

("#$$*+ &$* &$$/ %"*+'*+$/ *$%$ *$%$ $('"* ,$'**$.

;'''. R'$$/ P",$*++$$* H-#-%

P$('"* /'&$# "*$ %",$#-#$* ",$*++$$* -#-%

("",-%*$.

'. S"#(-$,

O'"*/$(' ("#(-$, $('"* *!%$, /'&$# "*$

%"*+$,$%' "*+$*'$$$* ("#(-$, &$* /'&$# $&$ +"


11/36


%"%-*>'/. P"*$%',$* $('"* ("(-$' &"*+$* -('$*$. P!/!*+$*

$%-/ "*&"# "$*$ '/$% &$* $' #-,'/ "$*$ ($!

%$/$*+. K""('$* &'' $('"* >-#- /"$$)

P$('"* >-#- #!!"$/' &-&-# ($*/$' &$* /$%$# /"*$*+

%"*-#- $-( '>$$ *!%$, ;!,-%" (-$$

("&$*+ &$* $/'#-,$(' $$$*

*. '++D DAN AFEK

M!!& ) "-/'%'#

A"# )appropiate

K"("$('$* ) ("$('

,. PIKIRAN

1. B"*/-# 7 P!("( P'#'

P!&-#/';'/$( ) >-#-

K!*/'*-'/$( '#'$* ) >-#-


11


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H"*&$$ B"$$($ ) /'&$# /"+$*++-

Flight of Ideas ) /'&$# $&$

A(!('$(' ,!*++$ ) /'&$# $&$

Blocking ) /'&$# $&$

S'#-%/$*('$,'/$( ) /'&$# $&$

T$*+"*('$,'/$( ) /'&$# $&$

Word salad ) /'&$# $&$

Clang association ) /'&$# $&$

I*#!""*(' ) /'&$# $&$

V"'+"$(' ) /'&$# $&$ P"(";"$(' ) /'&$# $&$

A%';$,"*(' ) /'&$# $&$

2. I(' P'#'

F!'$ ) /'&$# $&$

O("(' ) /'&$# $&$

K!%-,(' ) /'&$# $&$

I&" -*- &'' ) /'&$# $&$

@$$% ) $&$

o @$$% bizzare

P$('"* %"$($ &''*$ ("$+$' $*$# C"!;$ &$* -*$

#"%$%-$* -*/-# %"*"%-#$* !$*+ ($#'/ ("/$

%"%$*+#'/#$* !$*+ %$/'.

o @$$% #""($$*

P$('"* %"*+$/$#$* $*$ &'$ $*+ %$%-

"#!%-*'#$(' #"$&$ C"!;$ &$* C"!;$ (",$,-

%"*+$-,#$* "%'*/$$**$. P$('"*


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o @$$% #"'-% $- %'*$# $*+'.

2. I,-(' ) /'&$# $&$

3. D""(!*$,'($(' ) /'&$# $&$

4. D""$,'($(' ) /'&$# $&$

/. SENS+RIU' DAN K+NITIF

1. K"($&$$*

compos mentis=G:S 1 E4VM6?


13


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2. F-*+(' K!+*'/'

O'"*/$('

o

@$#/- ) B$'# $('"* %$%- %"*+"/$-' "$/ &$* "--/$*.

o J$*+#$ "*&"#) B$'# $('"* &$$/ %"*+'*+$/ %"*-

%$#$* $+' =*$(' -&-#? &$* %"*- %$#$* %$,$% $'

#"%$'* =*$(' &$* $$% +!"*+?.

o J$*+#$ ("&$*+ ) B$'# $('"* %$(' &$$/ %"*+'*+$/#"+'$/$* ("$' $' &' S$*$/!'-% D$%$$*+($

$('"* '.

3. K!*("*/$(' &$* A/"*('

S",$%$ $$*>$$ #!*("*/$(' $('"* >-#- $'# $('"*

%$%- %"*+'#-/' &"*+$* $'# $,- "/$*$$* $*+ &'$$ &$* M"*-,'(

B$'#. P$('"* &$$/ %"%$>$ /-,'($* P$# 5$,& $' '*'

$$+'$ #$"*$ %$#$* *$(' +!"*+ &$* $('"* &$$/ %"*-,'(#$*


14


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#$,'%$/ ("&"$*$ $*+ &'&'#/"#$* !," "%"'#($ "-$ 5$,& $#$*

%$#$* !$/ /"$/- (-$$ >"$/ -,$*+

. K"%$%-$* K$,#-,$('

S",$%$ $$*>$$ #!*("*/$(' >-#- $'# /'&$# /"$,'#$*

&"*+$* $('"* ,$'* $*+ "'('# $&$ ($$/ %",$#-#$* $$*>$$.

P$('"* &$$/ %"*+'#-/' &$* %"*-#- (!$*.

2. DA3A NI&AI

1. RTA

T"+$*++- #$"*$ $&$*$ $$% &$* $,-('*$('.

2. T','#$*


1+


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D"$$$ #$"*$

&. T",'*+$ ) "*/-# *!%$, /'&$# $&$ ("#"/. ". M-,-/ ) '' ,"%$ ,'&$ /'&$# #!/! caries dentis=?

. J$*/-*+

I*("#(' ) -,($(' '#/-( #!&'( /'&$# /",'$/.

P$,$(' ) '#/-( #!&'( /'&$# /"$$

P"#-(' ) $/$(


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. A&!%"*

I*("#(' ) $&!%"* /$%$# %"%-*>'/.

P$,$(' ) "$ &$* ,'"* /'&$# /"$$.

P"#-(' ) /'%$*'.

A-(#-,/$(' ) '('*+ -(-( *!%$,

'. E#(/"%'/$( $/$( ) $#$, $*+$/ 7 "&"% 7 &"!%'/$( 7 *"' 7


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K'%'$ &$$

F-*+(' $/'

P!/"'*

P!/"'* T!/$,

A,-%'*G,!-,'*

B','-'*

T!/$,

D'"#

I*&'"#

SGOT SGPT

SGOT

SGPT

K$!'&$/

GDP

G,-#!($ 2 J$% PP

F-*+(' G'*% BB #+ #-,'/ "$*$ ($! %$/$*+.

P!/!*+$* $%-/ "*&"# "$*$ '/$% &$* $' #""('$* >-#- /"


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P$&$ /$-* 2009 ($%$' /$-* 2012 $('"* #",-$ &$' S$*$/!'-% D$%$-#- $'# $('"* $+$# %"*$'# &'' &$' "+$-,$*.

D$' "%"'#($$* '('# (/$/-( *"-!,!+'# &$* "%"'#($$* ,$!$/!'-%

$('"* /'&$# &' &$$/#$* $, $*+ "%$#*$.

1II. DIAN+SIS

B"&$($#$* $(', $$*>$$ "%"'#($$* '('# &$* ,$!$/!'-% $*+

%"*+$>- $&$ PPDGJIII %$#$ &$$/ &'('%-,#$* ("$+$' "'#-/)

A7IS I6

1. B"&$($#$* +"


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4. K"%-*&-$* '*/","#/-$, ) /'&$# $&$

. T'&$# /"&$$/ #",$'*$* !+$*'# $*+ &$$/ &'#$'/#$* &"*+$* +$*++-$*


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o H$,-('*$(' !,$#/!'# &'%$*$ $('"* %"*>'-% $- #!/!$* $/$-

($%$ &$* $- %'*$# $*+'.

M$#$ &$$/ &'('%-,#$* $$ $('"* %"*&"'/$ SCHIZOPHRENIA

TYPE PARANOID.

A7IS II6

D$' $,,!$*$%*"($ &'('%-,#$* $$ $('"* /'&$# %"%','#' +$*++-$*

#"'$&'$* &$* /'&$# $&$ "/$&$(' %"*/$,. =5 03.2?

A7IS III6

D$' $,,!$*$%*"($ $-/!$*$%*"($ &$* $(', "%"'#($$* ,$ $('"*

%"%','#' "*$#'/ D'$"/"( M",,'/-( /'" 2 =E11? &$* H'"/"*(' =I10? $*+

/"#!*/!, &"*+$* !$/.

A7IS I16

B"&$($#$* $-/!$*$%*"($ &'/"%-#$* (/"(! ('#!(!('$, &$* ,'*+#-*+$*

$*+ %"%"*+$-' #!*&'(' $('"* ($$/ '*' $'/- #",-$+$ $*+ %"*+->',#$*

$('"* &$* %"*+$*++$ $('"* "#$( ($#'/


22/36


GAF =HLPC?) 0 61 =""$$ +"$$ -%-% %$(' $'#?. P$('"* &$$/ %",$#-#$*

#"+'$/$**$ ("*&'' /$*$ $*/-$* !$*+ ,$'*.

1III. E1A&UASI 'U&TI A7IA&

A#('( I ) F20.0 S#'!"*'$ P$$*!'&.

A#('( II ) T'&$# $&$. 5 03.2

A#('( III ) D'$"/"( M",,'/-( /'" 2. E11

H'"/"*('. I10A#('( IV ) P$('"* %"$($ &'#->',#$* !," #",-$+$

A#('( V ) GAF =HLPC? ) 061

GAF =:-"*/? ) 061

I7. F+R'U&ASI TERAPI

A. Farmak!l!gi

A''$!, 1 1 %+ PO =$+' $'? ("$+$' !$/ $*/'('#!/'# +"*"$('

#"&-$.

M"/!%'* 3 00 %+ PO =("",-% %$#$*? ("$+$' !$/ D'$"/"(

M",,'/-( /'" 2.

A%,!&''*" 1 %+ PO =$+' $'? ("$+$' !$/ H'"/"*('.

B. N!n 8armak!l!gi

P('#!/"$') #upportie Therap'

o P"*+$$($* %'*-% !$/ $+$ +"$$ /"$/- &"%'

#"("%-$**$.

o M"%!/';$(' &$* %"%"' &-#-*+$* #"$&$ $('"* -*/-# &$$/

%",$#-#$* $#/';'/$( ("!/'%$, %-*+#'*.

T"$' P('#!(!('$,

o Famil' Counseling)



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M"%"' '*!%$(' #"$&$ #",-$+$ $('"* /"*/$*+

"*$#'/ $*+ &'&"'/$ $('"* &$* "*/'*+*$ &-#-*+$*

("/$ %!/';$(' &$,$% #"$/-$* "*+!$/$* $('"*.

o (ccupational Theraph') M"*+'#-/ ("/$#$* $('"* &$,$% #"+'$/$* %",$/'

#"/"$%',$* "-$ #"$


24/36


P"


25/36


9aat berbi:ara; tiba < tiba #aien mengangkat tangan "an men%entikkan %ari a a ering mun:ul "i kamar aya9haluinai >iual=.

A ) B!," /$- P$# C"!;$ '/- (""/' $$

B ) C"!;$ $ +'/- C!,$ ba"annya tinggi; bear; memakai %ubah #utih yang

berinar; e#erti ba#ak < ba#ak; %engg!tan. Kaya #atung yang "i gere%a;

#eri e#erti itu 9haluinai >iual=.

A ) S$%" ("#$$*+ %$(' ("'*+ ,'$/ C"!;$ $#

B ) C$ #$&$*+ #$&$*+ $


26/36


A ) C$*+ (-#$ *+!%!*+ &' #"$,$ $$# $&$ "$$ !$*+

B ) A$,*$ ($/- C!,$ teru lama < lama %a"i banyak9haluinai au"it!rik=.

A ) B$*$# '/- ('$$ ($


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A ) I/- ("'*+ P$#

B ) I$ ("'*+ C!,$.

A ) P$$*!%$,*$ "*$ %-*>-,'* &'' +$# P$#

B ) G$# "*$ (' C!,$.

A ) K$,! !," /$- $$# $+$'%$*$ '($ %$(-# #" D$%$$*+($

B ) S$$ &'$$ ($%$ #$#$# ($$. D'$ '#' ($$ +',$ #$"*$ ($$ '($ &"*+$ (-$$

C"!;$. L'$/ $


28/36


H$,-('*$(' ;'(-$, ) $&$

H$,-('*$(' !,$#/!'# ) $&$

S/""!/''# ) $&$


8


29/36


@A@AN:ARA 2

H$'7/$*++$, ) S"*'* 30 M"' 2016

J$% ) 10.00 @IB

P"*$%',$* ) B$$ "-($$$* $*+ %$*$

B ) P"-($$$* !,' -*$ #",-$+$ ($$ 9waham kebearan=.

A ) T$&' $$# ',$*+ "-($$$**$ $*$# /-( &' $+' $+' #" ($-&$$ $$#

-*$ "$$ $*$# ($-&$$

B ) S$$ /-a "an memang

aya "ilahirkan ke "unia ebagai anak 3eh!>a 9waham kebearan=.

A ) S$-&$$ ($-&$$ $$# (-#$ &$/$*+ +$# ,'$/'* $$#

B ) G$# "*$ C!,$ %$#$*$ ($$ #$&$*+ (-#$ #"(",. P$&$$, %""#$ '($ (""/'

("#$$*+ $ #$"*$ ($$


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#eruahaan aya. 'ereka %uga #egang tabungan aya "i bank 9waham

kebearan=.

A ) T$-*+$**$ "%$*+ $*$# P$#

B ) A"a bera#a milyar gitu; 9#aien tertawa= lu#a angking banyaknya 9waham

kebearan=.

A ) U$*+ &' /$-*+$**$ +$# $'( $# K$* &'$#$' /"-( ($%$ ($-&$$.

B ) C$ '($ >-%$* #$,$- $'( ($$ /'*++$, %'*/$ $-%$* C"!;$ $


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B ) G$# "*$ ,$+' >-%$* $( &-,- $*+"/ &' +""!*/! /!'> $*+ &'&'(#-('#$* ($%$ C"!;$ $$ $!$ $# +$%$


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A ) P$# >! $$>$ /-,'($* '*' $# ="%"'#$ %"*-,'( P$# 5$,& $' '*' $$+'$

#$"*$ %$#$* *$(' +!"*+?

B ) =P$('"* %"%$>$ /-,'($* P$# 5$,& $' '*' $$+'$ #$"*$ %$#$* *$(' +!"*+

&"*+$* $'# &$* "*$?

A ) P$# >!$ ($$ &'#/" /-( $$# /-,'( $*+ ($$ !%!*+'* $ =P"%"'#($ %"*&'#/"

#$,'%$/ 5$,& $#$* %$#$* !$/ /"$/- (-$$ >"$/ -,$*+?.

B ) =P$('"* %"*-,'( #$,'%$/ 5$,& $#$* %$#$* !$/ /"$/- (-$$ >"$/ -,$*+

&"*+$* $'# &$* "*$?.

A ) K$* $$# $#-*/$* *' !," ($$ /"( +$# '/-*+ '/-*+$* $$#

B ) B!," &!*+ C!,$.

A ) K$,$- 100 &'#-$*+ "$$ P$#

B ) H$$$ 93 ,$ C!,$ %$($ +'/- $


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P"*$%',$* ) K$!( "#"$ #"% >",$*$ "*&"# '-

A#/';'/$( ) B"$'* "-($$$**$ +'%$*$ /-

$#

B ) I/- (!$, "#!*!%' $


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A ) H$$$$.. "$/' #$$ $&- #-$/ #-$/$* $ P$#. K$,! +'/- $$# '($ *!,!*+'*

!$*+ &!*# ,"$/ C"!;$

B ) B'($ /$' &-,- $#/- ($$ %$(' $&$ ! #-&-(. Dulu !rang buta bia aya

embuhin l!h; !rang meninggal bia hi"u# lagi.T$' ("#$$*+ ($%$ C"!;$ -&$

&' $%', ,$+' ! #-&-(*$. K$/$*$ $$ ($%$

C"!;$ 9waham bi??are=.

A ) B$$# $+$%$*$ K'(/"* $/$- K$/!,'#

B ) S$$ K$/!,'# C!,$ &$* ($$ '/- /"%$(-# $$$.

B ) I$ "*" #$,! +$# *+"$($'* ("*&'' %$ +$# $#$* ">$$.

A ) P$# #$,$- ($$ "$/''* #!+ $$#


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B ) I*+"/ &!*+ C!,$ ($$ &-,- /'*++$, &' S-*/" #$"*$ -%$ ($$ ("'*+ #"$*


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K"($&$$* ) compos mentis

M!!& ) "-/'%'#

A"# ) appropiate

@$$% bizzare ) $&$

@$$% #""($$* ) $&$

GRAFIK PERJALANAN PENYAKIT

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