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RSUD PALEMBANG BARI RM.SRF.1
ANAMNESISRuang : ...................................... No. Rek.Med : ..........................
Nama : ....................................... Umur L/P : ................................
Tanggal :
Dari : pasien sendiri / ayah / ibu / orang lain
Dokter Muda : .......................................
Dokter : ..............................................
RSUD PALEMBANG BARI RM.SRF.2
PEMERIKSAAN FISIKRuang : ...................................... No. Rek.Med : ..........................
Nama : ....................................... Umur L/P : ................................
A. Status PraesensKesadaran : ......................................Gizi : ......................................Suhu Badan : ......................................Nadi : ......................................Pernapasan : ......................................Tekanan Darah : ......................................Berat Badan : ......................................Tinggi Badan : ......................................
Status PsikisSikap : ......................................Perhatian : ......................................
Status InternusJantung : .....................................................Paru : .....................................................Hepar : .....................................................Lien : .....................................................Anggota Gerak : .....................................................Genetalia : .....................................................
Ekspresi Muka : .....................................................Kontak Psikis : .....................................................
B. Status Neurologis1. Kepala
Bentuk : ...............................................Ukuran : ...............................................Simetris : ...............................................
2. LeherSikap : ........................................Torticollis : ........................................Kaku kuduk : ........................................
Deformitas : ..............................................Tumor : ..............................................Pembuluh darah : ..............................................
C. Syaraf-syaraf Otak1. N. Olfaktorius Kanan
Penciuman : ................................................................Anosmia : ................................................................Hyposmia : ................................................................Parosmia : ................................................................
2. N. OptikusVisus : ................................................................
Campus Visi
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PEMERIKSAAN FISIKRuang : ...................................... No. Rek.Med : ..........................
Nama : ....................................... Umur L/P : ................................ Kanan
- Anopsia : ................................................................- Hemianopsia: ................................................................
Fundus oculi- Papil edema : ................................................................- Papil atrofi : ................................................................- Perdarahan retina : ........................................................
3. N. Oculomotorius, Trochlearis, dan Abducen KananDiplopia : ................................................................Celah mata : ................................................................Ptosis : ................................................................Sikap bola mata : .............................................................- Strabismus : ................................................................- Exopthalmus: ................................................................- Enopthalmus: ................................................................- Deviation conjuge : .......................................................Gerakan bola mata : ........................................................Pupil : ................................................................- Bentuk : ................................................................- Diameter : ................................................................- Iso/Anisokor: ................................................................- Midriasis/Miosis : .........................................................- Refleks Cahaya : ...........................................................
• Langsung : ................................................................• Konsensuil : ................................................................• Akomodasi : ................................................................
- Argyl Robetson : ...........................................................
4. N. TrigeminusMotorik Kanan- Menggigit : ................................................................- Trismus : ................................................................- Refleks kornea : ............................................................Sensorik- Dahi : ................................................................- Pipi : ................................................................- Dagu : ................................................................
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PEMERIKSAAN FISIKRuang : ...................................... No. Rek.Med : ..........................
Nama : ....................................... Umur L/P : ................................
5. N. FacialisMotorik Kanan- Mengerutkan dahi : ......................................................- Menutup mata : ..............................................................- Menunjukkan gigi : .......................................................- Lipat nasolabialis : ........................................................- Bentuk muka
• Istirahat : ....................................................................• Bicara/bersiul : ............................................................
Sensorik- 2/3 depan lidah : ........................................................
Otonom- Salivasi : ........................................................................- Lakrimasi : ....................................................................
Chovstek’s sign : .............................................................
6. N. Cochlearis Kanan
Suara bisikan : ................................................................Detik arloji : ................................................................Test Weber : ................................................................Test Rinne : ................................................................
7. N. Vagus dan Glossopharingeous
Arcus pharynx : ..............................................................Uvula : ................................................................Gg. Menelan : ................................................................Suara bicara : ................................................................Denyut jantung : ..............................................................Refleks- Muntah : ................................................................- Batuk : ................................................................- Oculocardiac : ...............................................................- Sinus caroticus : ............................................................
Sensorik- 1/3 belakang lidah : .......................................................
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RSUD PALEMBANG BARI RM.SRF.5
PEMERIKSAAN FISIKRuang : ...................................... No. Rek.Med : ..........................
Nama : ....................................... Umur L/P : ................................
8. N. Acessorius Kanan- Mengangkat bahu : ........................................................- Memutar kepada : .........................................................
9. N. Hypoglosus Kanan
Menjulurkan lidah : .........................................................Fasikulasi : ................................................................Atrofi papil lidah : ..........................................................Dysatria : ................................................................
Kiri......................................................................................................................................
Kiri............................................................................................................................................................................................................................................................................
D. Columna VertebralisKyphosis : ........................................................................................................................................
Scoliosis : ........................................................................................................................................
Lordosis : ........................................................................................................................................
Gibbus : ........................................................................................................................................
Deformitas : ........................................................................................................................................
Tumor : ........................................................................................................................................
Meningocele: ........................................................................................................................................
Hematoma : ........................................................................................................................................
Nyeri ketok : ........................................................................................................................................
RSUD PALEMBANG BARI RM.SRF.6
PEMERIKSAAN FISIKRuang : ...................................... No. Rek.Med : ..........................
Nama : ....................................... Umur L/P : ................................
E. Badan dan Anggota GerakMotorik
Lengan Kanan- Gerakan : ................................................................- Kekuatan : ................................................................- Tonus : ................................................................- Refleks fisiologis
• Biceps : ................................................................• Triceps : ................................................................• Periost Radius : ...........................................................• Periost Ulna : ..............................................................
- Refleks patologis • Hoffman Tromner : ....................................................
- Trofik : ..........................................................................
Tungkai Kanan- Gerakan : ................................................................- Kekuatan : ................................................................- Tonus : ................................................................- Klonus : ................................................................
• Paha : ................................................................• Kaki : ................................................................
- Refleks fisiologis• KPR : ................................................................• APR : ................................................................
- Refleks patologis • Babinsky : ................................................................• Chaddock : ................................................................• Oppenheim: ................................................................• Gordon : ................................................................• Schaeffer : ................................................................• Rossolimo : ................................................................• Mendel Bechtereyev : ................................................
- Refleks kulit perut• Atas : ................................................................• Tengah : ................................................................• Bawah : ................................................................• Tropik : ................................................................
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RSUD PALEMBANG BARI RM.SRF.7
PEMERIKSAAN FISIKRuang : ...................................... No. Rek.Med : ..........................
Nama : ....................................... Umur L/P : ................................
Sensorik:
F. G A M B A R
RSUD PALEMBANG BARI RM.SRF.8
PEMERIKSAAN FISIKRuang : ...................................... No. Rek.Med : ..........................
Nama : ....................................... Umur L/P : ................................
G. Gejala Rangsang Meningeal Kanan- Kaku kuduk : ................................................................- Kernig : ................................................................- Lassergue : ................................................................- Brudzinsky
• Neck : ................................................................• Cheeck : ................................................................• Symphysis : ................................................................• Leg I : ................................................................• Leg II : ................................................................
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H. Gait dan KeseimbanganGait
- Ataxia : ................................................................- Hemiplegic : ................................................................- Scissor : ................................................................- Propulsion : ................................................................- Histeric : ................................................................- Limping : ................................................................- Steppage : ................................................................- Astasia-abasia : ..............................................................
Keseimbangan- Romberg : .....................................- Dysmetri : .....................................
• Jari - jari : .....................................• Jari - hidung : .....................................• Tumit - tumit : .....................................• Dysdiadochokinesis : ..........................• Trunk ataxia : .....................................• Limb ataxia : .....................................
I. Gerakan Abnormal- Tremor : .......................................................................................................................................- Chorea : .......................................................................................................................................- Athetosis : .......................................................................................................................................- Ballismus : .......................................................................................................................................- Dystoni : .......................................................................................................................................- Myoclonic : .......................................................................................................................................
J. Fungsi Vegetatif- Miksi : .......................................................................................................................................- Defekasi : .......................................................................................................................................- Ereksi : .......................................................................................................................................
K. Fungsi Luhur- Afasia motorik : ................................................................................................................................- Afasia sensorik : ................................................................................................................................- Afasia nominal : ................................................................................................................................- Apraksia : ................................................................................................................................- Agrafia : ................................................................................................................................- alexia : ................................................................................................................................
RSUD PALEMBANG BARI RM.SRF.9
PEMERIKSAAN PENUNJANG
Ruang : ...................................... No. Rek.Med : ..........................
Nama : ....................................... Umur L/P : ................................Laboratorium Darah : Urine : Faeces :
Liquor Cerebro Spinal - Warna : ................................................................- Kejernihan : ................................................................- Tekanan : ................................................................- Jumlah Sel : ................................................................- Nonne : ................................................................
- Protein : .....................................- Glukose : .....................................- Queckensted : .....................................- Kultur : .....................................- Pandy : .....................................
Pemeriksaan Khusus- Ro. Cranium : ..............................................................................................................................- Ro. Thorax : ..............................................................................................................................- Coll. Vertebralis : ..............................................................................................................................- ElectroEncephaloGraphy : ........................................................................................................................- Arteriography : ..............................................................................................................................- Electrocardiography : ..............................................................................................................................- Pneumigraphy : ..............................................................................................................................- Lain-lain : ..............................................................................................................................
DIAGNOSA KLINIK : ....................................................................................................................
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DIAGNOSA TOPIK : ....................................................................................................................
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DIAGNOSA ETIOLOGI : ....................................................................................................................
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RSUD PALEMBANG BARI RM.SRF.10
RINGKASANRuang : ...................................... No. Rek.Med : ..........................
Nama : ....................................... Umur L/P : ................................Anamnesis :
Pemeriksaan :
Diagnosa Klinik : ....................................................................................................................
Diagnosa Topik : ....................................................................................................................
Diagnosa Etiologi : ....................................................................................................................
Pengobatan :
Pembuat catatan medik, Dokter Muda,
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Dokter Penanggung Jawab,
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RSUD PALEMBANG BARI RM.SRF.11
Lembar Follow-Up Dokter Muda
Nama Pasien : ............................... Ruang Rawat : .................................. No. MedRec: ............
Umur : ................. L/P Dokter Muda : .................................
Tanggal / Pkl Perjalanan Penyakit Instruksi / Rencana Therapy