REFLEKSI KASUS.2012

7/23/2019 REFLEKSI KASUS.2012

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REFLEKSI KASUS

SKIZOFRENIA PARANOID

DISUSUN OLEH :

ASBIA MUSABIAT01.207.5478

DWI PUTRA SETIANTO 01.207.5433

ENDAH KUMALA DEWI 01.207.5478

SHAHER BANUN 01.207.5562

FAKULTAS KEDOKTERAN UNIERSITAS ISLAM

SULTAN A!UN!

SEMARAN!

2012


2/10

I. IDENTITAS PASIEN

N"#" : N$. A

%&'() K&*"#(' : P&+,-"'

U#-+ : 37 T"-'

A/"#" : I)*"#

A*"#" : P"'"+ II RT. 05 02 S"*"#"' M"/&*"'/

P&&+""' : T(" B&&+"

P&'(("' : SLTA

S-- : %""

M")- RS : 1582012

II. RIWAYAT PSIKIATRI

D"+( 1 2

N"#" N$. S T'.S

U#-+ 64 "-' 75 T"-'

A*"#" M-'(*"' M-'(*"'

P&&+""' I- R-#" T"'//" W(+")")"

P&'(("' SMP SMP

H--'/"' I- K"'-'/ A$" K"'-'/

L"#" K&'"* S&" L"(+ S&" L"(+

S(9" ,&+&'"*"' A+" K-+"'/ A+"

T," R-#" R-#"

A-"'"#+&)() (,&+*&

N$. A; 37 "-'; ( B"'/)"* W4 "' +-#" ,")(&'; "'//"* 1< "' 21 O&+

2012

a. S&" ("" & R-#" S"(

P")(&' ("" &+-#" )"( *& K"" I,"+'$" "+&'" #&'/"'"#

""' #-'- +"'/ &'/"' ,()"-


3/10

b. R("$" P&'$"( S&"+"'/

K-+"'/ *&( 25 "-' $"'/ *"*- ,")(&' &+-)(" 12 "-' ,")(&' (('//"*

*& ,&'/")-'$". K&&+""' ,")(&' #&'"( )-" #"+"; &+"" )&'(+(

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

K"+&'" ")("'; ,&'/")-'$" "*( *"/( "' ,")(&' "*( '+#"*.

S&*"'/ 3 -*"' ,&'/")-'$" #&'('//"* "' ,")(&' "*( #&'/"*"#(

/"'//-"'. K-("' ,")(&' ("" ( RS% P+9. D+. S&+" M"/&*"'/

"' #&'"," ,&'/""' "' ,")(&' "," &+)&*" "*(; #&)(,-'

""'/ #")( #-" #"+" -+"'/ *&( 4 "-' -("' )"" ,&'&+("

&+-)(" 16 "-' "' &" ,&'&+(" ,&+/( & B""# -'- &&+" "'

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

"*( #&'/"#-. S"" *& &*-"+/"'$" ,")(&' ("" & RS% ,+9

S&+$" "' (+"" = 1 #('//-. K-("' ,")(&' ,-*"'/ +"" "*"'

"' +-(' #('-# "; /&"*" #")( )&+('/ #-'-*. S"" ,")(&' *-*-) SMU

,")(&' #&*"'-"' & &'"'/ ,&+-*(""' "' #&'/"#(* S1&",( "'$"

&+""' )"- )&)&+ "' ,")(&' #&+")" &)-*("' -'- #&*"'-"'.

S&" (- ,")(&' )&+('/ #"+"#"+"; #&'/"'"# ""' #-'-

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

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

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

#&'/"'"# ""' #-'- "$"'$". P")(&' &+-)&+-)"' #"+" "'

#('" ("" & RS% P+9 D+. S&+ M"/&*"'/. A(+'$" *&

&*-"+/"'$" ,")(&' ("" & RS%.

III. RIWAYAT PENYAKIT DAHULU

a. P)(("+(

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

"") ('(")( &+ "' ""'/ "-+.

b. M&() U#-#

P")(&' "," ("""' (" ,&+'" )"( &+" )&" *"(+ )"#,"( )""

#' ( RS.

c. P&'//-'""' " > ""' ?" "((9 "' "**

P")(&' (" #,-'$"( &(")""' #&'//-'""' " > ""'; "**

#&'/(- * "' ?" "(9 *"(''$".

IV. RIWAYAT PRIBADI


4/10

a. P+&'""* "' P&+('""*

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

#,*(")( #&(. P")(&' ""*" "'" &5 "+( 5 &+)"-"+". K&"#(*"'

(" ("+","' "+&'" (- ,")(&' )-" &+-)(" 41 "-'. P")(&' *"(+

'+#"*; --, -*"' &+" ""' *"(+ 3200 /+; *"'/)-'/ #&'"'/()

b. M")" "'" > "'" ""*

P")(&' (")- *& ,&'/")-; (-+ &+"-+ &+)"#" ,&'/")-'$". M('-#

ASI )"#,"( 1;5 "-' "," &+"*"' -)(" 2 "-'; &+("+" -)(" 3 "-'.

T(*& +"(''('/ (""+"' )&" -)(" 1;5 "-' &",( ,")(&' #")( )&+('/

#&'/#,*.

c. M")" "'" > "'" ,&+&'/""'

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

&+'"#" I+". P")(&' #(*(( "' &" &+'"#" "( "' #")(

#&'/#,* )"#,"( -)(" 6 "-'. P")(&' #&+-,""' "'" $"'/ #(*((

,&+/"-*"' *-") "' )&'"'/ &*""+. P")(&' #&'"," +"'/('/ 4 ( S&*"

D")"+.

d. M")" "'" > "'" "' +""

P")(&' #-*"( #&'/"*"#( /"'//-"'; &",( #")( "," &+)&*" "'

#&+"( ,+&)")( ""(. P")(&' ,&+'" #(*(( &")( &",(

-("' ,--) "+&'" ,")(&' )-" #"+"#"+".

R("$"

E'&-+)() @

S'"#-*()# @

A-() @

ADHD @

!"'//-"' &*""+ @

!(/( "+( @ T,&+"+-# @

S"" &+)&*" ,")(&' ,&+'" (-**$ *& ""'""''$". P")(&'

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

(-+(.

e. M")" +""

1. R("$" P&&+""'

P")(&' &*-# ,&+'" &&+"

2. R("$" P&+"('"' "' ,&+)""""'


5/10

P")(&' #&'(" 2; ("' "'," ,")""' ,")(&' #&'("

,&+"#" "'$" &+""' 3 -*"'; "+&'" ,")(&' #"+". P&+'(""'

&-" #&'/")(*"' )&+"'/ "'"; &+"", "'" )-" #&'/"'"#

""' #-'-

3. R("$" #(*(&+

K&*-"+/" #"-,-' ,")(&' (" ,&+'" &+--'/"' &'/"' #(*(&+

4. R("$" ,&'(("'

P")(&' &+)&*" '&/&+( "' #&*"'-"' )"#,"( S1 @ )&)&+ )"-;

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

5. R("$" &"/"#""'

P")(&' &+"/"#" I)*"#; (" )*" "' (" #&'/(-( ,&'/"("'

6. R("$" "(C("") ))("*

T(" ""

7. S(-")( (-, )&"+"'/

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

)-" #"+" > #"+" #&'/"'"# ""' #-'- )-"#( "' "'".

8. R("$" --#

P")(&' (" ,&+'" &+--'/"' &'/"' --#

f. R("$" P)()&)-"*

P")(&' &+('/" *"- )&,&+( ,&+,-"'; #&')+-")( )"" &+-)(" 12

"-'.

g. R("$" K&*-"+/"

D(+-#" ,")(&' "'$" "+", &'/"' &-"'$"

P")(&'


6/10

K&&+"'/"'

: K&*-"+/" &'/"' &*-"' $"'/ )"#"

: P&'&+("

: P&+,-"'

: L"( > *"(

: M&'('//"*

h. M(#,(; "*"$"'"' '(*"( (-,

P")(&' (" ,&+'" &+"$"*; &+#(#,( $"'/ "'&

V. STATUS MENTAL

a. !"#"+"' U#-#

P&'"#,(*"' : "#," "'(" )&)-"( -#-+; &+,""("';,&+"""' (+( "(.

P&+(*"- : H(,"(9 : "#," "'(" )&)-"( -#-+;

&+,""("'; ,&+"""' (+( "(.

S(", &+"", ,&+()""'; &&+" )"#"

b. M "' A9&

a. M : D(9+(

b. A9& : -#,-*

c. K&)&+")("' : A,,+,+("&

c. B("+"

a. K-"(") : D&+&")&

b. K-"*(") : L

d. !"'//-"' P&+)&,)(

a. H"*-)('")( : A-('(

b. I*-)( : A-(+(

e. P((+"'

a. P+/&),((+ : A-()(

b. I)( : W""# B(?"+&


7/10

c. B&'- : R#('/

f. S&')+(-# "' /'()(

a. K&"),"""' "' ('/" &)""+"' "(

b. O+(&'")( WTOS &+'(

c. D"$" ('/" "- &*-# *"#" "+-)"" )&/&+" "(

d. K')&'+")( "' ,&+"("' "(

e. ()-"),")("* : "(

f. B&+,((+ ")+" "(

g. P&'/&'"*("' (#,-*) "(

h. T(*("' )""+ ""' ,&'$"('$"

i. R&*("(*(") A**'"#'&)() : "*(

A-"'"#'&)() : "*(

VI. PEMERIKSAAN FISIK UMUM

a. S"-) I'&+'-) :

K&"""' -#-# : "(; M; )"-) /(?( "(

W"" : (" #'/*(

T"'" C("* :

TD : 120 75 ##H/

N"( : 64#'

R&,(+")( : 20#'

S-- : "9&+()

K&,"*" : K'-'/(C" (" "'(); )*&+" (" (&+(

L&&+ : )(#&+(); %P (" #&'('/"

THT "' 9-'/)( ,&'&'/"+"' &)"' (" "" &*"('"'

M"" "' 9-'/)( ,&'/*(""' : &)"' (" "" &*"('"'

+ : K'9(/-+")( "' &)" "*"# "") '+#"*S12#-+'( /"**, @ #-+#-+ @

P-*# : S(#&+(); )'+; C&)(-*&+

A#"' : )-,&*; ,&+()"*(@; '+#"* NT @

E)+(") : T(" "" &*"('"'

b. S"-) N&-+*/()

N+ +"'("*&) : (" "" &*"('"'

R&9*& F()(*/() :

R&9*& P"*/() :


8/10

c. L"+"+(-#

P&+()""' H")(* N(*"( N+#"*

RB 4;5106 4.005.00

HB 12;4


9/10

VIII. FORMULA DIAGNOSTIK

S(+# S(+# S(+# S(+# S(+#

") D&,+&)( M"'( S(?9+&' P"+"'#"

W. B&+)"*"@ I& #"( #()( -+(/"

W. B&+)"@ W. '+* W. K&"+

A9& D()9+( W. S("+ ,((+ W. D("'"#

W. S()(, ,((+

A,& -#,-*

F. 20.0 S(?9+&'(" P"+"'"(

M&'-( +(&+(" -#-# ("/')() )(?9+&'(" $"

S&"/"( "#""'

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

a. S-"+" "*-)('")( $"'/ #&'/"'"; ,")(&' #&+( ,&+('"

"*-)('")( "-(+( "'," &'- C&+"* ("

b. H"*-)('")( ,"-"'c. W""# (&'"*("' (,&'/"+-( ,)((9 (&+"+ $"

!"'//-"' "9&(9 $"

F.20.3 S?9+&'(" " &+('(

M&'-( +(&+(" -#-# -'- ("/')() )(?9+&'(" $"

T(" #&'-( +(&+(" ,"+"'( &&9+&'( ""'( ("

T(" #&'-( +(&+(" )(?9+&'(" +&)(-*

&,+&)( ,")" )(?9+&'(" ("

IX. DIAGNOSIS MULTIAKSIAL

A)() I : F. 20.0 S(?9+&'(" ,"+"'(

A)() II : (" "" ("/+)()

A)() III : &*-# "" ("')()

A)() I : #")( ,+(#"+$ )-,,+ /+-,; #")"*" ,&'(("'

(('//""* ,&'/")-'$" B-**$('/

A)() : !AF M-"(+ : 5041

!AF )"" #")- RS : 2011

!AF &+"( (- &+"(+ : 5041


10/10

X. PRONOSIS

O')& M-"

S+&))+ @

K&,+("("' E+"C&+ > S(?(

%&'() ,&'-,(( S(?9+&'

F"+ +/"'( @

P*" &*-"+/" @

S"( & 10

B&+"," *"#" &"'/"' #&() 1 "-'

K&)(#,-*"' "" #"*"#

XI. PENATA LAKSANAAN

a. P)(9"+#""

b. N' P)(9"+#"&1. M&+( ,&'&*")"' &'"'/ +"'/ -" #&'/&'"( /"'//-"' )(?9+&'

,"+"+(

2. B&&+" )"#" &'/"' +&" ,)())("* -'- #&'/"'/"'

"#,-"' ,&'&+("

3. B&&+")"#" &'/"' &*-"+/" "' ,&'&+(" -'- &&+"-+"'

#('-# ".

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REFLEKSI KASUS.2012