RSUD PALEMBANG BARI

ANAMNESIS

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Ruang : ...................................... No. Rek.Med : ..........................
Nama : .......................................

Umur L/P : ................................

Tanggal :

Dokter Muda : .......................................

Dari

Dokter

: pasien sendiri / ayah / ibu / orang lain

: ..............................................

RSUD PALEMBANG BARI

PEMERIKSAAN FISIK

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Ruang : ...................................... No. Rek.Med : ..........................
Nama : .......................................

A. Status Praesens
Kesadaran
Gizi
Suhu Badan
Nadi
Pernapasan
Tekanan Darah
Berat Badan
Tinggi Badan

:
:
:
:
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:
:

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Status Psikis
Sikap
Perhatian

: ......................................
: ......................................

Status Internus
Jantung
Paru
Hepar
Lien
Anggota Gerak
Genetalia

Ekspresi Muka
Kontak Psikis

Umur L/P : ................................

:
:
:
:
:
:

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: .....................................................
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B. Status Neurologis
1. Kepala
Bentuk : ...............................................
Ukuran : ...............................................
Simetris : ...............................................
2. Leher
Deformitas
: ..............................................
Sikap
: ........................................
Tumor
: ..............................................
Torticollis : ........................................
Pembuluh
darah
: ..............................................
Kaku kuduk : ........................................
C. Syaraf-syaraf Otak
Kiri
1. N. Olfaktorius
Kanan
...................................................................
Penciuman : ................................................................
Anosmia : ................................................................ ...................................................................
Hyposmia : ................................................................ ...................................................................
Parosmia : ................................................................ ...................................................................
2. N. Optikus
Visus
: ................................................................
Campus Visi

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PEMERIKSAAN FISIK

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Nama : ....................................... Umur L/P : ................................

Kanan
Kiri
- Anopsia
: ................................................................ ...................................................................
- Hemianopsia: ................................................................ ...................................................................
Fundus oculi
- Papil edema : ................................................................
- Papil atrofi : ................................................................
- Perdarahan retina : ........................................................

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3. N. Oculomotorius, Trochlearis, dan Abducen

Kanan
Diplopia
: ................................................................
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 : ...........................................................

Kiri
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4. N. Trigeminus
Motorik
Kanan
- Menggigit : ................................................................
- Trismus
: ................................................................
- Refleks kornea : ............................................................
Sensorik
- Dahi
: ................................................................
- Pipi
: ................................................................
- Dagu
: ................................................................

Kiri
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PEMERIKSAAN FISIK

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Nama : .......................................

5. N. Facialis
Motorik
Kanan
- Mengerutkan dahi : ......................................................
- Menutup mata : ..............................................................
- Menunjukkan gigi : .......................................................
- Lipat nasolabialis : ........................................................
- Bentuk muka
Istirahat : ....................................................................
Bicara/bersiul : ............................................................
Sensorik
- 2/3 depan lidah

: ........................................................

Umur L/P : ................................

Kiri
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Otonom
- Salivasi : ........................................................................ ...................................................................
- Lakrimasi : .................................................................... ...................................................................
Chovsteks sign : .............................................................

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6. N. Cochlearis
Kanan
Suara bisikan : ................................................................
Detik arloji : ................................................................
Test Weber : ................................................................
Test Rinne
: ................................................................

Kiri
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7. N. Vagus dan Glossopharingeous

Arcus pharynx : ..............................................................
Uvula
: ................................................................
Gg. Menelan : ................................................................
Suara bicara : ................................................................
Denyut jantung : ..............................................................
Refleks
- Muntah
: ................................................................
- Batuk
: ................................................................
- Oculocardiac : ...............................................................
- Sinus caroticus : ............................................................

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Sensorik
- 1/3 belakang lidah : ....................................................... ...................................................................

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PEMERIKSAAN FISIK

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Nama : .......................................

Umur L/P : ................................

8. N. Acessorius
Kanan
Kiri
- Mengangkat bahu : ........................................................ ...................................................................
- Memutar kepada : ......................................................... ...................................................................
9. N. Hypoglosus
Kanan
Menjulurkan lidah : .........................................................
Fasikulasi
: ................................................................
Atrofi papil lidah : ..........................................................
Dysatria
: ................................................................

Kiri
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D. Columna Vertebralis
Kyphosis

: ........................................................................................................................................

Scoliosis

: ........................................................................................................................................

Lordosis

: ........................................................................................................................................

Gibbus

: ........................................................................................................................................

Deformitas : ........................................................................................................................................
Tumor

: ........................................................................................................................................

Meningocele : ........................................................................................................................................
Hematoma : ........................................................................................................................................
Nyeri ketok : ........................................................................................................................................

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PEMERIKSAAN FISIK

RM.SRF.6

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Umur L/P : ................................

E. Badan dan Anggota Gerak

Motorik
Lengan
Kanan
- Gerakan
: ................................................................
- Kekuatan : ................................................................
- Tonus
: ................................................................
- Refleks fisiologis
Biceps
: ................................................................
Triceps
: ................................................................
Periost Radius : ...........................................................
Periost Ulna : ..............................................................
- Refleks patologis
Hoffman Tromner : ....................................................
- Trofik : ..........................................................................

Kiri
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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
: ................................................................

Kiri
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RSUD PALEMBANG BARI

PEMERIKSAAN FISIK

RM.SRF.7

Ruang : ...................................... No. Rek.Med : ..........................

Nama : .......................................

Sensorik:

F. G A M B A R

Umur L/P : ................................

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PEMERIKSAAN FISIK

RM.SRF.8

Ruang : ...................................... No. Rek.Med : ..........................

Nama : .......................................

G.

Gejala Rangsang Meningeal

Kanan
- Kaku kuduk : ................................................................
- Kernig
: ................................................................
- Lassergue : ................................................................
- Brudzinsky
Neck
: ................................................................
Cheeck
: ................................................................
Symphysis : ................................................................
Leg I
: ................................................................
Leg II
: ................................................................

Umur L/P : ................................

Kiri
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H.

Gait dan Keseimbangan

Keseimbangan
Gait
: .....................................
- Ataxia
: ................................................................ - Romberg
: .....................................
- Hemiplegic : ................................................................ - Dysmetri

Jari
jari
: .....................................
- Scissor
: ................................................................

Jari
hidung
: .....................................
- Propulsion : ................................................................
Tumit - tumit : .....................................
- Histeric
: ................................................................
Dysdiadochokinesis : ..........................
- Limping
: ................................................................
Trunk ataxia : .....................................
- Steppage
: ................................................................
Limb ataxia : .....................................
- Astasia-abasia : ..............................................................

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

PEMERIKSAAN
PENUNJANG
Laboratorium
Darah :

RM.SRF.9

Ruang : ...................................... No. Rek.Med : ..........................

Nama : .......................................
Urine :

Liquor Cerebro Spinal

- Warna
: ................................................................
- Kejernihan
: ................................................................
- Tekanan
: ................................................................
- Jumlah Sel
: ................................................................
- Nonne
: ................................................................

Umur L/P : ................................

Faeces :

- 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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RINGKASAN

Ruang : ...................................... No. Rek.Med : ..........................

Nama : .......................................

Umur L/P : ................................

Anamnesis :

Pemeriksaan :

Diagnosa Klinik

: ....................................................................................................................

Diagnosa Topik

: ....................................................................................................................

Diagnosa Etiologi
Pengobatan :

: ....................................................................................................................

Pembuat catatan medik,

Dokter Muda,

Dokter Penanggung Jawab,

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

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

Lembar Follow-Up Dokter Muda

Nama Pasien : ...............................

Ruang Rawat : ..................................

Umur : ................. L/P

Dokter Muda : .................................

Tanggal / Pkl

Perjalanan Penyakit

No. MedRec: ............

Instruksi / Rencana Therapy

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RM.SRF.12