status ujian rehabilitasi medik
TRANSCRIPT
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
ANAMNESIS Ruang :……………………….. No.Rek.Med :……………………………
Nama :……………………….. Umur / Jeni :……………………… L / P
A!ama" :……………………………………………. Agama :……………………
Peker#aan : …………………………………………… S"a"u $erka%inan :……………………
&angga! $emerikaan :……………………………………. 'ok"er muda :……………………
(
1. ANAMNESIS
2. KELUHAN UTAMA
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3. RIWAYAT PENYAKIT SEKARANG………………………………………………………………………………………………….
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4. RIWAYAT PENYAKIT / OPERASI DAHULU………………………………………………………………………………………………….
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5. RIWAYAT PENYAKIT PADA KELUARGA
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). RIWAYAT PEKERJAAN………………………………………………………………………………………………
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7. RIWAYAT SOSIAL EKONOMI
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
PEMERIKSAAN FISIK Ruang : No.Rek.Med :
Nama : Umur : L / P
PEMERIKSAAN FISIK Ruang : No.Rek.Med :
*
II. PEMERIKSAAN FISIK
A. Pemerikaan Umum
Keadaan Umum : +aik / edang / +uruk
Keadaran : G , S :
&inggi Badan / Bera" Badan : -m / kg BMI :
,ara +er#a!an / Gai"
♠ An"a!gik gai" :.............................................................................................
♠ emi$aree gai" :……………………………………………………………
♠ S"e$$age gai" : .............................................................................................
♠ Parkinon gai" : .............................................................................................
♠ &rede!en+erg gai" : .............................................................................................
♠ add!e gai" : .............................................................................................
♠ Lain 0 !ain : .............................................................................................
Baa!a / "#$a%a
Komunikai 1er+a! : .............................................................................................
Komunikai non1er+a!: .............................................................................................
Ta&'a (#)a*
&ekanan dara2 : / mmg
Nadi : 3 / meni"
Perna4aan : 3 / meni"
Su2u : ,
K+*#) :
S)a)+! P!#,#!
Sika$ : 5rien"ai :........................................
Ek$rei %a#a2 : Per2a"ian :........................................
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
Nama : Umur : L / P
6
B. Sa%a- !a%a- )a,
Ner1u kanan kiri
I. N.5!4ak"oriu ……………... .................
II. N.5$"i-u ....................... .................
III. N.5--u!omo"oriu ....................... ..................
I7. N.&ro-2!eari ....................... .................
7. N.&rigeminu ....................... .................
7I. N.A+du-en ....................... ...................
7II. N.Fa-ia!i ...................... ...................
7III. N.7e"i+u!ari ...................... ...................
I8. N.G!oo$2ar9ngeu ...................... ....................
8. N.7agu ....................... ....................
8I. N.a--eoriu ....................... ....................
8II. N.9$og!ou ........................ ....................
,. Ke$a!a
Ben"uk : ............................................................................................................
Ukuran : ............................................................................................................
Poii :.............................................................................................................
Ma"a :.............................................................................................................
idung :.............................................................................................................
&e!inga :............................................................................................................ Mu!u" : ............................................................................................................
a#a2 : ime"ri / aime"ri gerakan a+norma! : ………………
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
PEMERIKSAAN FISIK Ruang : No.Rek.Med :
Nama : Umur : L / P
PEMERIKSAAN FISIK Ruang : No.Rek.Med :
;
'. Le2er
In$eki :…………………………………………………………………………………
Pa!$ai : ………………………………………………………………………………..
Lua Gerak Sendi
An"e / re"ro4!eki < n )= / => ? : ………/………….
La"ero4!eki < '/S ? < n ;> / ;> ? :………/………….
Ro"ai < '/S ? < n ;= / ;= ? : ………/………..
&e" $ro1okai
L2ermi""e "e" / S$ur!ing :……………… &e" 7a!a!1a :……………………….
'i"raki "e" :……………… &e" Na4@iger :……………………….
E. &2orak
Ben"uk :……………………………………………………….
Pemerikaan Ek$ani &2orak : Ek$irai makimum .......,m In$irai Makimum ..........-m
Pa%+0 a%+
In$eki : …………………………………………………………………………..
Pa!$ai :…………………………………………………………………………..
Perkui : ………………………………………………………………………….
Auku!"ai : ……………………………………………………………………………..
Ja&)+&
In$eki : ……………………………………………………………………………..
Pa!$ai : …………………………………………………………………………….
Perkui : ……………………………………………………………………………..
Auku!"ai : ……………………………………………………………………………..
F. A+domen In$eki : …………………………………………………………………………….
Pa!$ai : …………………………………………………………………………….
Perkui : …………………………………………………………………………….
Auku!"ai : ……………………………………………………………………………
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
Nama : Umur : L / P
Ruang : No.Rek.Med :
=
G. &runku
In$eki :
Sime"ri :………………………………………………………………………….
'e4ormi"a :…………………………………………………………………………..
Lordoi :…………………………………………………………………………..
S-o!ioi :………………………………………………………………………….
Gi++u :………………………………………………………………………….
air9 $o" :…………………………………………………………………………..
Pe!1i- &i!" :…………………………………………………………………………
Pa!$ai :
S$ame o"o"o"o" $ara 1er"e+rae :…………………………………………………………
N9eri "ekan < !okai ? :…………………………………………………………
Lua gerak endi !um+oakra!
An"e /re"ro 4!eki
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
PEMERIKSAAN FISIK / NEUR5L5GI Nama : Umur : L / P
)
N+%*#
Mo"orik 'e3"ra Sini"ra
Gerakan .............................. ........................................
Kekua"an .............................. ........................................
A+duki !engan .............................. ........................................
F!eki iku ............................... ........................................
Ek"eni iku ............................... ........................................
Ek"eni ri" ............................... .........................................
F!eki #ari #ari "angan ............................... ........................................
A+duki #ari "angan ............................... ........................................
&onu ............................... .........................................
&ro$i ............................... ........................................
Re4!ek Fiio!ogi
Re4!ek "endon +ie$ ............................... .......................................
Re4!ek "endon "rie$ .............................. ......................................
Re4!ek Pa"o!ogi
o44man ............................... .......................................
&romner .............................. ........................................
Senorik
Pro"o$a"ik :.....................................................................................................................
Pro$rioe$"ik :....................................................................................................................
7ege"a"i4 :....................................................................................................................
P*a#a& -+&!# )a&a& kanan kiriAna"omi-a! ................ ..................
Gri$ ................ ..………….
S$read …………. .…………..
Pa!mar a+du-" …………. ……………
Pin-2 …………. …………....
Lum+ri-a! .……….... …………….
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
PEMERIKSAAN FISIK / LGS Ruang : No.Rek.Med :
Nama : Umur : L / P
L+a! %a, !&'# Ak"i4 Ak"i4 Pai4 Pai4
'e3ra ini"ra 'e3ra Sini"ra
A+duki +a2u ………… ............. .................. ................
Adduki +a2u ………… ……….. ................. ................
F!eki +a2u .............. ............... .................. ................
E3"eni +a2u ............... ................ ................. ................
Endoro"ai +a2u ? ................ ................ ................. ..................
Ekoro"ai +a2u ? ................. ................. .................. ...................
Endora"ai +a2u ? ................. ................. .................. ..................
Ekoro"ai +a2u ? .................. ................. ................... ...................
F!eki iku ................. ................ ................... ...................
Ek"eni iku .................. .................. .................. ...................
Ek"eni $erge!angan "angan .................. .................. .................. ....................
F!eki $erge!angan "angan ................... .................. .................. ....................
Su$inai .................... ………….. ………….. …………….
Pronai …………… ………….. ………….. …………….
&e" Pro1okai kanan kiri
Dergaon "e" : ………………… ………………….
A$!e9 -ra"-2 "e" : ………………… …………………
Moe!e9 "e" : ………………… ………………….
Adon manu1er : ………………… …………………
&ine! "e" : ………………… …………………
P2a!en "e" : ………………… ………………….
Pra9er "e" : ……………….. …………………
Finke!"ein : ……………….. ………………..
Prome" "e" : ………………… …………………
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
PEMERIKSAAN FISIK Ruang : No.Rek.Med :
Nama : Umur : L / P
I. Anggo"a Gerak Ba%a2
In$eki kanan kiri
'e4ormi"a : ……………….. ………………
Edema : ………………. .......................
&remor : ......................... .......................
Pa!$ai
N9eri "ekan < !okai ? : ........................... ..........................
'ikre$ani : ........................... ..........................
N+%*#
Mo"orik kanan kiri
Gerakan ........... ...........
Kekua"an
F!eki $a2a ............ ..............
Ek"eni $a2a ............ ..............
Ek"eni !u"u" ............ ...............
F!eki !u"u" ............. ...............
'oro4!eki $erge!angan kaki ............. ................
'oro4!eki i+u #ari kaki .............. ................
P!an"ar 4!eki $erge!angan kaki .............. ...............
&onu ............... ................
&ro$i ................ ...................
Re4!ek Fiio!ogi
Re4!ek "endo $a"e!!a ................ …………...
Re4!ek "endo a-2i!!e ………… …………..
Re4!ek $a"o!ogi
Ba+ink9 …………… ……………
,2addo-k …………… ……………
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
PEMERIKSAAN FISIK / LGS Ruang : No.Rek.Med :
Nama : Umur : L / P
S&!%#, kanan kiri
Pro"o$a"ik : ……………. ……………….
Pro$rioe$"ik : ……………. ………………
)a)#- : ……………. ………………
L+a! %a, !&'#
Lua gerak Ak"i4 Ak"i4 Pai4 Pai4
Sendi 'e3"ra Sini"ra 'e3"ra Sini"ra
F!eki $a2a ……… ………. ………… ………..
Ek"eni $a2a ……… ………. ………… ………..
Endoro"ai $a2a ……… ………. ………… ………..
Adduki $a2a ……… ………. ………… ………..
A+duki $a2a ……… ………. ………… ………..
F!eki !u"u" ……… ………. ………… ………..
Ek"eni !u"u" ……… ………. ………… ………..
'oro4!eki $erge!angan kaki ……… ………. ………… ……….
P!an"ar 4!eki $erge!angan kaki ……… ………. ………… ……….
In1eri kaki ……… ………. ………… ……….
E1eri kaki ……… ………. ………… ……….
T!) P%(,a!# !&'# *+)+) ,a&a& ,#%#
S"re "e" ................ ...................
'ra%erC "e" ................ ....................
&e" &une! $ada endi !u"u" ................. ....................
&e" oman ................. ....................
&e" !ain 0 !ain ................... ....................
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
PEMERIKSAAN FISIK Ruang : No.Rek.Med :
Nama : Umur : L / P
(>
III. P%#,!aa&0 %#,!aa& *a#&&6a
Pemerikaan re4!ek 0re4!ek $rimi"i1e $ada anak 0anak dengan gangguan SSP
Rig2"ing rea-"ion :…………………………………………………
Reaki keeim+angan :…………………………………………………
Pemerikaan !ainn9a :…………………………………………………
Bo%e! "e" / B!adder "e"
Senorik $eri ana! :………………………….
Mo"orik $2in-"er ani ek"ernu :………………………….
B,R < Bu!+o-a1ernoi Re4!ek :………………………….
Fungi !u2ur
A4aia :………………………………………………….
A$rakia :………………………………………………….
Agra4ia :…………………………………………………
A!e3ia :………………………………………………….
I. PEMERIKSAAN PENUNJANG
A. Radio!ogi :
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B. La+ora"orium :
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,. Lain 0!ain ,& 0 S-an / MRI :
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
RESUME Ruang : No.Rek.Med :
Nama : Umur : L / P
((
. RESUME
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
EALUASI / DIAGNOSIS Ruang : No.Rek.Med :
Nama : Umur : L / P
(*
I. EALUASI
N5 Le1e! I,F Kondii aa" ini Saaran
( S"ruk"ur dan 4ungi "u+u2 ……………………………..
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* Ak"i1i"a ……………………………..
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6 Par"ii$ai ……………………………..……………………………..
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,a"a"n : I,F In"erna"iona! ,!ai4i-a"ion o4 Fun-"ion < 5 *>>* ?
DIAGNOSIS KLINIS
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
PROGRAM REHABILITASI Ruang : No.Rek.Med :
Nama : Umur : L / P
(6
II. PROGRAM REHABILITASI MEDIK
F#!#)%a#
&era$i $ana :.............................................................................................................
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&era$i dingin :.............................................................................................................
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S"imu!ai !i"rik :..............................................................................................................
.............................................................................................................. &era$i !a"i2an : .............................................................................................................
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O,+a!# )%a#
R5M e3-er-ie : .......................................................................................
A'L E3-er-ie : .......................................................................................
O%))#, %!))#, 5r"o"i- :................................................................................................
Pro"e"i- : ...............................................................................................
A!a" +an"u am+u!ai :................................................................................................
T%a# #$a%a
A4aia : ................................................................................................
'9ar"ria :.................................................................................................
'94agia :.................................................................................................
S$#a* '#, :.................................................................................................
E'+,a!# :..................................................................................................
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FK UNSRI PALEMBANG RM.R
BAGIAN REHABILITASI MEDIK
TERAPI
PROGNOSA / FOLLOW UP
Ruang : No.Rek.Med :
Nama : Umur : L / P
PEMERIKSAAN FISIK Ruang : No.Rek.Med :
Nama : Umur : L / P
Mmmm
(;
III. TERAPI MEDIKAMENTOSA
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I8 . PROGNOSA
M'#, 9……………………………………………………………………………
0 F+&!#&a* 9…………………………………………………………………………….
8 . FOLLOW UP
Ta&a* 9…………………………………………………………………………….
K*+a& 9 …………………………………………………………………………….
P%#,!aa& U+ 9 …………………………………………………………………………….
Ka'aa& ,+!+! 9 …………………………………………………………………………….
F+&!#&a* 9 Ba%)* I&': 9
FIM I&': 9
Ka); #&': 9