status mhasiswa update

FK UNSRI PALEMBANG RM.R BAGIAN REHABILITASI MEDIK

ANAMNESIS Ruang :……………………….. No.Rek.Med :……………………………

Nama :……………………….. Umur / Jenis :………………………L / PAlamat :……………………………………………. Agama :……………………

Pekerjaan : …………………………………………… Status perkawinan :…………………….

Tanggal pemeriksaa :…………………………………….. Dokter muda :……………………

1

I. ANAMNESIS

1. KELUHAN UTAMA ………………………………………………………………………………………………….

2. RIWAYAT PENYAKIT SEKARANG …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. ………………………………………………………………………………………………….

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3. RIWAYAT PENYAKIT / OPERASI DAHULU …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. ………………………………………………………………………………………………….

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4. RIWAYAT PENYAKIT PADA KELUARGA ………………………………………………………………………

…………………………………………………………………………………………………. ………………………………………………………………………………………………….

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5. RIWAYAT PEKERJAAN ……………………………………………………………………

…………………………………………………………………………………………………6. RIWAYAT SOSIAL EKONOMI ………………………………………………………………………………………………….

…………………………………………………………………………………………………


PEMERIKSAAN FISIK Ruang : No.Rek.Med :Nama : Umur : L / P

2

II. PEMERIKSAAN FISIK

A. Pemeriksaan Umum

Keadaan Umum : baik / sedang / buruk

Kesadaran : G C S :

Tinggi Badan / Berat Badan : cm / kg BMI :

Cara berjalan / Gait

Antalgik gait :.............................................................................................

Hemiparese gait :……………………………………………………………

Steppage gait : .............................................................................................

Parkinson gait : .............................................................................................

Tredelenberg gait : .............................................................................................

Waddle gait : .............................................................................................

Lain – lain : .............................................................................................

Bahasa / bicara

Komunikasi verbal : .............................................................................................

Komunikasi nonverbal: .............................................................................................

Tanda vital

Tekanan darah : / mmHg

Nadi : x / menit

Pernafasan : x / menit

Suhu : C

Kulit :

Status Psikis

Sikap : Orientasi :........................................

Ekspresi wajah : Perhatian :........................................



3

B. Saraf – saraf otak

Nervus kanan kiri

I. N.Olfaktorius ……………... .................

II. N.Opticus ....................... .................

III. N.Occulomotorius ....................... ..................

IV. N.Trochlearis ....................... .................

V. N.Trigeminus ....................... .................

VI. N.Abducens ....................... ...................

VII. N.Fascialis ...................... ...................

VIII. N.Vestibularis ...................... ...................

IX. N.Glossopharyngeus ...................... ....................

X. N.Vagus ....................... ....................

XI. N.accesorius ....................... ....................

XII. N.Hypoglosus ........................ ....................

C. Kepala

Bentuk : ............................................................................................................

Ukuran : ............................................................................................................

Posisi :.............................................................................................................

- Mata :.............................................................................................................

- Hidung :.............................................................................................................

- Telinga :............................................................................................................

- Mulut : ............................................................................................................

- Wajah : simetris / asimetris gerakan abnormal : ………………



4

D. Leher Inspeksi :…………………………………………………………………………………

Palpasi : ………………………………………………………………………………..

Luas Gerak Sendi

Ante / retrofleksi ( n 65 / 50 ) : ………/………….

Laterofleksi ( D/S ) ( n 40 / 40 ) :………/………….

Rotasi ( D/S ) ( n 45 / 45 ) : ………/………..

Test provokasi

Lhermitte test / Spurling :……………… Test Valsalva :……………………….

Distraksi test :……………… Test Nafziger :……………………….

E. Thorak

Bentuk :……………………………………………………….

Pemeriksaan Ekspansi Thoraks : Ekspirasi maksimum .......Cm Inspirasi Maksimum ..........cm

Paru- paru

- Inspeksi : …………………………………………………………………………..

- Palpasi :…………………………………………………………………………..

- Perkusi : ………………………………………………………………………….

- Auskultasi : ……………………………………………………………………………..

Jantung

- Inspeksi : ……………………………………………………………………………..

- Palpasi : …………………………………………………………………………….

- Perkusi : ……………………………………………………………………………..

- Auskultasi : ……………………………………………………………………………..

F. Abdomen

- Inspeksi : …………………………………………………………………………….

- Palpasi : …………………………………………………………………………….

- Perkusi : …………………………………………………………………………….

- Auskultasi : ……………………………………………………………………………



5

G. Trunkus

Inspeksi :

Simetris :………………………………………………………………………….

- Deformitas :…………………………………………………………………………..

- Lordosis :…………………………………………………………………………..

- Scoliosis :………………………………………………………………………….

- Gibbus :………………………………………………………………………….

- Hairy spot :…………………………………………………………………………..

- Pelvic Tilt :…………………………………………………………………………

Palpasi :

- Spasme otot-otot para vertebrae :…………………………………………………………

- Nyeri tekan ( lokasi ) :…………………………………………………………

Luas gerak sendi lumbosakral

- Ante /retro fleksi (95/35) :……………./……………..

- Laterofleksi (D/S) (40/40) :……………/……………...

- Rotasi (D/S) (35/35) :……………./…………….

Test provokasi

- Valsava test :…………Tes Laseque :…./…….Test : Baragard dan Sicard :

……./……….

- Niffziger test : …………Test SLR :…./……. Test: O’Connell :

……./………

- FNST :…../…….Test Patrick :…. /…….Test Kontra Patrick :……/ ………

- Test Gaenslen :…../…….Test Thomas:…. /……. Test Ober’s :……/………

- Nachalas knee flexion test :……../…….. Mc.Bride sitting test :……./……..

- Yeoman’s hyprextension :……../…….. Mc.Bridge toe to mouth sitting test ;……./……..

- Test Schober :

………………………………………………………………………………

H. Anggota Gerak Atas

Inspeksi kanan kiri


PEMERIKSAAN FISIK / NEUROLOGI

Ruang : No.Rek.Med :Nama : Umur : L / P

6

Neurologi

Motorik Dextra Sinistra

Gerakan . ............................. ........................................

Kekuatan .............................. ........................................

Abduksi lengan .............................. ........................................

Fleksi siku ............................... ........................................

Ekstensi siku ............................... ........................................

Ekstensi Wrist ............................... .........................................

Fleksi jari- jari tangan ............................... ........................................

Abduksi jari tangan ............................... ........................................

Tonus ............................... .........................................

Tropi ............................... ........................................

Refleks Fisiologis

Refleks tendon biseps ............................... .......................................

Refleks tendon triseps .............................. ......................................

Refleks Patologis

Hoffman ............................... .......................................

Tromner .............................. ........................................

Sensorik

Protopatik :.....................................................................................................................

Proprioseptik :....................................................................................................................

Vegetatif :.......................................................................................................

Penilaian fungsi tangan kanan kiri

Anatomical ................. .........................

Grips ................. ……………….

Spread …………. ……………….

Palmar abduct …………… …………………

Pinch …………… ………………...


PEMERIKSAAN FISIK / LGS Ruang : No.Rek.Med :Nama : Umur : L /

P

7

Luas gerak sendi Aktif Aktif Pasif Pasif

Dexra sinistra Dexra

Sinistra

Abduksi bahu ………… ............. .................. ................

Adduksi bahu ………… ……….. ................. ................

Fleksi bahu .............. ............... .................. ................

Extensi bahu ............... ................ ................. ................

Endorotasi bahu (f0) ................ ................ ................. ..................

Eksorotasi bahu (f0) ................. ................. .................. ...................

Endoratasi bahu (f90) ................. ................. .................. ..................

Eksorotasi bahu (f90) .................. ................. ................... ...................

Fleksi siku ................. ................ ................... ...................

Ekstensi siku .................. .................. .................. ...................

Ekstensi pergelangan tangan .................. .................. .................. ....................

Fleksi pergelangan tangan ................... .................. .................. ....................

Supinasi .................... ………….. ………….. …………….

Pronasi …………… ………….. ………….. …………….

Test Provokasi kanan kiri

- Yergason test : ………………… ………………….

- Apley scratch test : ………………… …………………

- Moseley test : ………………… ………………….

- Adson manuver : ………………… …………………

- Tinel test : ………………… …………………

- Phalen test : ………………… ………………….

- Prayer test : ……………….. …………………

- Finkelstein : ……………….. ………………..

- Promet test : ………………… …………………


PEMERIKSAAN FISIK Ruang : No.Rek.Med :Nama : Umur : L /

P

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I. Anggota Gerak Bawah

Inspeksi kanan kiri

- Deformitas : ……………….. ………………

- Edema : ………………. .......................

- Tremor : ......................... .......................

Palpasi

- Nyeri tekan ( lokasi ) : ........................... ..........................

- Diskrepansi : ........................... ..........................

Neurologi

Motorik kanan kiri

Gerakan ........... ...........

Kekuatan

Fleksi paha ............ ..............

Ekstensi paha ............ ..............

Ekstensi lutut ............ ...............

Fleksi lutut ............. ...............

Dorsofleksi pergelangan kaki ............. ................

Dorsofleksi ibu jari kaki .............. ................

Plantar fleksi pergelangan kaki .............. ...............

Tonus ............... ................

Tropi ................ ...................

Refleks Fisiologis

Refleks tendo patella ................ …………...

Refleks tendo achilles ………… …………..

Refleks patologi

Babinsky …………… ……………

Chaddock …………… ……………


PEMERIKSAAN FISIK / LGS Ruang : No.Rek.Med :Nama : Umur : L / P

9

Sensorik kanan kiri

- Protopatik : ……………. ……………….

- Proprioseptik : ……………. ………………

Vegetatif : ……………. ………………

Luas gerak sendi

Luas gerak Aktif Aktif Pasif PasifSendi Dextra Sinistra Dextra Sinistra

Fleksi paha ……… ………. ………… ………..

Ekstensi paha ……… ………. ………… ………..

Endorotasi paha ……… ………. ………… ………..

Adduksi paha ……… ………. ………… ………..

Abduksi paha ……… ………. ………… ………..

Fleksi lutut ……… ………. ………… ………..

Ekstensi lutut ……… ………. ………… ………..

Dorsofleksi pergelangan kaki ……… ………. ………… ……….

Plantar fleksi pergelangan kaki ……… ………. ………… ……….

Inversi kaki ……… ………. ………… ……….

Eversi kaki ……… ………. ………… ……….

Test Provokasi sendi lutut kanan kiri

Stres test ................ ...................

Drawer’s test ................ ....................

Test Tunel pada sendi lutut ................. ....................

Test Homan ................. ....................

Test lain – lain ................... ......................



RESUME Ruang : No.Rek.Med :Nama : Umur : L / P

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III. Pemeriksaan- pemeriksaan lainnya

Pemeriksaan refleks –refleks primitive pada anak –anak dengan gangguan SSP

Righting reaction :…………………………………………………

Reaksi keseimbangan :…………………………………………………

Pemeriksaan lainnya :…………………………………………………

Bowel test / Bladder test

- Sensorik peri anal :………………………….

- Motorik sphincter ani eksternus :………………………….

- BCR ( Bulbocavernosis Refleks :

………………………….

Fungsi luhur

- Afasia :………………………………………………….

- Apraksia :………………………………………………….

- Agrafia :…………………………………………………

- Alexia :………………………………………………….

IV. PEMERIKSAAN PENUNJANG

A. Radiologis :

……………………………………………………………………………..

……………………………………………………………………………...

……………………………………………………………………………...

………………………………………………………………………………

B. Laboratorium :

…………………………………………………………………………………

………………………………………………………………………………….

C. Lain –lain CT – Scan / MRI :

…………………………………………………………………………………..


RESUME Ruang : No.Rek.Med :Nama : Umur : L / P

11

V RESUME

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EVALUASI / DIAGNOSIS Ruang : No.Rek.Med :Nama : Umur : L / P

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VI. EVALUASI

NO Level ICF Kondisi saat ini Sasaran 1 Struktur dan fungsi tubuh ……………………………..

……………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………..……………………………..……………………………..

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2 Aktivitas ……………………………..……………………………..……………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………

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3 Partisipasi ……………………………..……………………………..……………………………………………………………………………………………………………………………………………………………………………………………….………………………………

……………………………..……………………………..……………………………………………………………………………………………………………………………………………………………………………………………….……………………………

Catatn : ICF International Clasification of Function ( WHO 2002 ) DIAGNOSIS KLINIS

.....................................................................................................................................................................

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PROGRAM REHABILITASI Ruang : No.Rek.Med :Nama : Umur : L / P

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VII. PROGRAM REHABILITASI MEDIK

Fisioterapi

Terapi panas :.............................................................................................................

.............................................................................................................

Terapi dingin :..............................................................................................................

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Stimulasi listrik :..............................................................................................................

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Terapi latihan : .............................................................................................................

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Okupasi terapi

ROM excercise : ....................................................................................... ADL Excercise : .......................................................................................

Ortotik prostetik Ortotic :................................................................................................

Prostetic : ...............................................................................................

Alat bantu ambulasi :................................................................................................

Terapi wicara Afasia : ................................................................................................

Dysartria :.................................................................................................

Dysfagia :.................................................................................................

Social medik :.................................................................................................

Edukasi :.................................................................................................. ..................................................................................................


TERAPI PROGNOSA / FOLLOW UP

Ruang : No.Rek.Med :Nama : Umur : L / P


Mmmm

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VIII. TERAPI MEDIKAMENTOSA

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IX . PROGNOSA

- Medik :……………………………………………………………………………

- Fungsional :…………………………………………………………………………….

X . FOLLOW UP Tanggal :…………………………………………………………………………….

Keluhan : ……………………………………………………………………………. Pemeriksaan Umum : …………………………………………………………………………….

Keadaan khusus : …………………………………………………………………………….

Fungsional : Barthel Index :

FIM Index :

Katz index :

status mhasiswa update

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