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DISUSUN OLEH:
ALFIANCA YUDHA RACHMANDA1102011020
DOKTER PEMBIMBING:
DR. ERI ACHMAD, SPKJ
PRESENTASI KASUS
Ski!"#$%i& P&#&%!i'
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STATUS PSIKIATRI
N&(& : N). N
J$%i* K$+&(i% : P$#$(-&%
U*i& : 2 /&-%
A&(& : I*+&(
A+&(&/ : B&%&%-%&%
S/&/-* $#k&3i%&% : M$%ik&
P$%'i'ik&% /$#&ki# : /i'&k 4$#*$k!+&
P$k$#&&% : D&&%
Di+&k-k&% A-/!&%&(%$*i* T&%&+ : 25 D$*$(4$# 201 T$(&/ : P!+i i3& RSUD A#&3i%&%-%
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II. KELUHAN
U/&(& : M$%'$%&# 4i*ik&%64i*ik&%
T&(4&&% : S$#i% 4$#4i7&#& *$%'i#i,+&#i6+&#i *$%'i#i '&% ($%&&k !#&%+&i% 4$#+&#i, ($+i&/ 4&)&%&% i/&(
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III. RIWAYAT PENYAKIT SEKARANG
P&*i$% '&/&% 'i&%/&# !+$ *-&(i%)& k$ !+i k+i%ik i3& RSUD A#&3i%&%-% -%/-k 7!%/#!+ 4$#!4&/.
&*i+ &-/!&%&(%$*i* &*i$% ($#&*& *$#i% &'&)&% ($(4i*iki, ($%)-#- 4$#+&#i '&% ($%&&k*$(-& !#&% +&#i.P&*i$% -& *$#i% ($+i&/4&)&%&% i/&(.&*i$% ($#&*& *$$#/i *-'&*$ki/&# 265 4-+&% '&% /$#&ki# ($%&+&(i k$(&#i%.
&*i+ &++!&%&(%$*i* *-&(i &*i$% 'i'&&/k&%4&3& &*i$% *$#i% 4i7&#& *$%'i#i, %&&k +&#i!#&% +&i% *$7&#& /i4&6/i4& /&%& ($%$%&+ 3&k/-'&% /i'&k /&- k$(&%&.
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S-&(i &*i$% ($%&/&k&% k$+-&% i%i *-'&'i&+&(i 5 4-+&% /$#&ki# i%i, '&+&( 1 (i%-/i'&k ($%$%/- 4i*& 265 &#i. S&(&i *&&/ 7!%/#!+&#i i%i *-&(i &*i$% -& ($%&/&k&% 4&3&$#/&(& k&+i &*i$% 'i4&3& k$ RS &'&+& 5
/&-% )&% +&+- '&% $#%& 'i#&3&/ 'i RSS-(4$# 8&#&* k&#$%& ($%&(-k *$$#/ik$*-#-&%.S-&(i &*i$% ($%&/&k&% &*i$%($%&+&(i *$$#/i i%i *$/$+& &%&k %)& -%)&(&*&+& k$+-&#& k&#$%& &%&k%)& 'i*$+i%k-i'&% 'i&%i&)& *-&(i%)&
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IV. WAWANCARA PSKIATRIK
Autoanamnesis1. Assalamualaikum bu Ya, walaikumsallam ok
!. P$#k$%&+k&% %&(& *&)& A#'i, %&(& i4- *i&&9 N&(& *&)& N). N '!k
". U(-# i4- *$k&#&% 4$#&& 9 2 / '!k
#. A&(&%)& && 4- 9 I*+&( '!k
$. P$%'i'ik&% /$#&ki# && 4- 9 Ti'&k *$k!+& '!k
%. S$k&#&% $k$#&&%%)& && 4- 9 '&&% '!k
&. A*+i%)& '&#i(&%& 4- 9 4&%&%-%&% '!k
'. I4- /&- *$k&#&% 4$#&'& 'i(&%& 9 Di #-(& *&ki/ RSUD &#&3i%&%-%
'!k,(. S&(& *i&& k$*i%i 4- 9 S&(& *-&(i '!k
1). A& k$+-&% )&% ($(4&3& i4- k$*i%i 9 K!%/#!+ '!k
11. O 4&ik, 4&&i(&%& *$k&#&% k$+-&%%)& 4- 9 (&*i &'& *-&#&6*-&#& 4i*ik&% '!k
1!. Bi*ik&% *$$#/i && 4- 9 S$$#/i &'& *-&#&6*-&#& )&%
($%)-#- *&)& '!k
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"$. 2aik bu sa+a mau betan+a +an lain +a bu, aaka-
ibu tau esamaan 0euk an ael /
Tiak ta-u
"%. K&+&- &'& '!($/ 'i&+&% && )&% I4- +&k-k&% 9 Y& 'ik$(4&ik&% '!k
"&. M&*i i%&/ %&(& *&)& 4-9 Ti'&k '!k
"'. P#$*i'$% *$k&#&% *i&& 4-9 J!k!3i '!k
"(. B&ik 4- k&+-& 4$i/- *$$#/i%)& *-'& 7-k-, /$#i(&k&*i
)& 4-
I)& '!k *&(&6*&(&
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A++!&%&(%$*i*1. Assalamualaikum ak Ya, walaikumsallam ok
!. P$#k$%&+k&% %&(& *&)& &+&%7&, %&(& 4&&k *i&&9 N&(& *&)& R '!k
". A& &k )&% 'ik$+-k&% i*/#i%)& S$#i% 4i7&#& *$%'i#i /$#-* *$#i%
%&&k +&#i &k /&- k$(&%&
#. Bi&*&%)& /$#&'i%)& P&i *i&% &/&- (&+&(9 Ti'&k /$%/- '!k
$. S-'& 4$#&& +&(& *$$#/i i%i9 5 4-+&% '!k
%. T$#&ki# k&&% *$$#/i i%i9 K$(&#i% '!k
&. 1 (i%- 4$#&& k&+i 9 265 &#i &% '!k
'. A3&+%)& k$%&& &k9 M&*&+& &%&k *&)& '!k
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(. *asala- aa/ Anak sa+a +an eemuan i
selinku-in
1). S$+&i% i/- &'& (&*&+& &&+&i &k 9 Ti'&k '!k
11. D-+- i4- $#%& 'i!4&/i9 P$#%& '!k
1!. Di(&%&9 K&&%9 S-(4$# 3&#&* '!k 5 /&-% +&+-
1". O4&/ %)& &&9 B&&i&(&%& *$/$+& 'i!4&/i 'i *-(4$# 3&#&*&k9
Ti'&k /&- '!k,Di#&3&/ '!k /$#-*/$/& *$$#/i i%i
1#. B&&i(&%& ($+&k-k&% &k/i;i/&* %)& 9 *$$#/i (&k&%, (&%'i,
/i'-# 9
Y& (&*i 4i*& '!k
1$. B&ik &k k&+-& 4$i/- *$$#/i%)& *-'& 7-k-, /$#i(&k&*i )&
&k
I)& '!k *&(&6*&(&
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V. RIWAYAT 3I45P
Penatal an PeinatalP&*i$% +&i# '$%&% $#*&+i%&% %!#(&+, 7-k- 4-+&% '&% 'i/!+!%4i'&%.
*asa Kanak Awal 6 )7" ta-un 8P&*i$% 'i-#-* !+$ !#&% /-& &*i$%. ($(-%)&i &%-&%
$%'$%&#&% *asa Kanak Petena-an 6 "7& ta-un 8
P&*i$% ($(i+iki i%/$#&k*i k-#&% 4&ik k&#$%& ($(i+iki &%-&%$%'$%&#&% *$&k k$7i+
*asa Kanak Ak-i an Rema0a
P&*i$% /i'&k 4$#*$k!+& '&% &%)& ($(4&%/- !#&% /-& *asa 4ewasa
Riwa+at eke0aan6
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Riwa+at enika-an ($%ik&
AamaI*+&(
Akti9itas sosial
Ak/i;i/&* *$*-&i '$%&% -*i&%)& Situasi ke-iuan sekaan Ti%&+ 4$#*&(& k$+-&#& '&% *&-'&#&%)&
Riwa+at -ukum Ti'&k $#%& &'& #i3&)&/ $+&%&#&% -k-(
Riwa+at sikoseksualP&*i$% ($(-%)&i !#&% &%&k
Riwa+at KeluaaP&*i$% &%&k k$ 5 '&#i < 4$#*&-'&#&. Ri3&)&/ &%-&% i3& &'&&%!/& k$+-&#& 'i*&%k&+.
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VI. RIWAYAT PENYAKIT 4A35:5 P*ki&/#ik '&% /$#&i : P$#%& 'i#&3&/ 'i RS
S-(4$# 8&#&* k-#&% +$4i 5 /&-% )&% +&+-
M$'i* '&% /$#&i : Ti'&k &'&
P$%)$+&-%&&% &/ : Ti'&k &'&
VII. PSIK<4INA*IKA
P#& (!#4i' : 4$#k$#i4&'i&% 3&&#, 4$#*!*i&+i*&*ik-#&% 4&ik
D-#&%/$ (!#4i' : &%-&% /$#&'i *$&k 5 /&-%)&% +&+-
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STAT5S *ENTA:
STAT5S *ENTA:
2easakan emeiksaan = 25 D$*$(4$# 201
I. 4ESKRIPSI 5*5* Penamilan
R&i '&&/ ($#&3&/ 'i#i Peilaku an akti9itas sikomoto T&(&k /$%&%
Sika te-aa emeiksa/i'&k k!$#&/i" =&%-&% $%'$%&#&%>
II. *<<4 4AN A>EK *oo = E-/i(i& A?ek = S$*-&i Keseasian A?ek = S$#&*i
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III. PE*2ICARAAN&%-&% &"&*i& (!/!#ik &'& $%'$%&#&%
IV. PERSEPSIH&+-*i%&*i &-'i/!#ik =?>, &+-*i%&*i ;i*-&+ =?>
V. PIKIRAN Poses Piki= K!$#$%
Isi Piki = 8&&% k$%'&+i =?>
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Konsentasi an e-atiank-#&% 4&ik k&#$%& /$#&%- '$%&% $%'$%&#&%%)&
Kemamuan membaa an menulis/i'&k 4&ik k&#$%& /i'&k *$k!+&
Pikian abstak Ti'&k B&ik, /i'&k 4i*& $#*&(&&% &$+ '$%&% $#-k
Inteleensia an kemamuan oanisasiB&ik, 4$%&# '&+&( ($%&3&4 #$*i'$% *$k&#&% &'&+&
J!k!3i Kemamuan menolon ii
B&ik, &'&%)& k$(&-&% -%/-k ($%!+!% *$%'i#i *$*-&i'$%&% #$*!% %!#(&+
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VII. PENGEN4A:IAN I*P5:SP&*i$% ($(i+iki !/$%*i -%/-k ($%)&ki/i 'i#i*$%'i#i '&% !#&% +&i%
VIII. 4AYA NI:AI 4AN TI:IKAN 4a+a Nilai Sosial = K-#&% 4&ik, &*i$% *-+i/
'&&/ 4$#k!(-%ik&*i %!#(&+ '$%&% $($#ik*&
50i 4a+a Nilai = B&ik, &*i$% ($(4$#ik&%
#$*!% '$%&% k$i%i%&% )&% *$*-&i '&% 4&ik Tilikan = Ti+ik&% <
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IB. TARA> 4APAT 4IPERCAYA P&*i$% /$#+i&/ --# '&% '&&/
'i$#7&)&
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PE*ERIKSAAN >ISIK
I. Status Intenus
&. K$&'&&% U(-( : B&ik
4. K$*&'&#&% : C!(!*($%/i*
7. T&%'&6/&%'& ;i/&+
i. T$k&%&% '&#& : 150@0
ii. N&'i : 0 @($%i/ iii. S-- : 5< C
i;. R$*i#&*i : 2 @($%i/
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II. EVA:5ASI *5:TIAKSIA:
II. E9aluasi *ultiaksial AKSIS I : F20.0 Ski!"#$%i& P&#&%!i'
AKSIS II : Ti'&k &'&
AKSIS III : P$%)&ki/ /$+i%&
AKSIS I : M&*&+& $#-(&&%
AKSIS : GAF <061 $&+& *$'&%,'i&*&4i+i/&* *$'&%
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IV. RENCANA TERAPI
Psiko?amaka C+!&i%$ 2 ( 21
Psikoteai Suoti? M$(4$#ik&% (!/i;&*i k$&'& &*i$%'&+&( ($%&'&i (&*&+& '&% *$+&+-($(4$#ik&% '!#!%&% &&# i'- +$4i
4&ik
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V. PR<GN<SIS
A' ;i/&( : A' 4!%&(
A' "-%7/i!%&( : A' (&+&(
A' *&%&/i!%&( : A' (&+&(
