STATUS UJIAN

KEPANITERAAN KLINIK SENIOR

ILMU PENYAKIT SARAF (NEUROLOGI)

NAMA

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

NIM

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

SEMESTER : ...............................................................
TANGGAL

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

PENGUJI

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

BAGIAN / DEPARTEMEN ILMU PENYAKIT SARAF (NEUROLOGI)

FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA / RSMH
PALEMBANG

STATUS PENDERITA NEUROLOGI

IDENTIFIKASI
Nama

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

Umur

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

Jenis Kelamin

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

Alamat

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

Agama

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

MRS Tanggal

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

ANAMNESA (Auto / Allo Anamnesa)

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PEMERIKSAAN
STATUS PRESENS
Status Internus
GCS = ........... (E: ., M: ....., V: .......)

Kesadaran

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

Gizi

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

Suhu Badan

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

Jantung

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

Nadi

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

Paru-paru

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

Pernapasan

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

Hepar

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

Tekanan Darah

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

Lien

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

Berat Badan

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

Anggota Gerak: ....................................

Tinggi Badan

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

Genitalia

Sikap

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

Ekspresi Muka: ....................................

Perhatian

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

Kontak Psikik: ....................................

Bentuk

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

Deformitas

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

Ukuran

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

Fraktur

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

Simetris

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

Nyeri fraktur

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

Hematom

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

Pembuluh darah: ....................................

Tumor

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

Pulsasi

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

Status Psikiatrikus

Status Neurologikus
KEPALA

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

LEHER
Sikap

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

Deformitas

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

Torticolis

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

Tumor

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

Kaku kuduk

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

Pembuluh darah

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

SYARAF-SYARAF OTAK
N. Olfaktorius

Kanan

Kiri

Penciuman

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

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

Anosmia

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

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

Hyposmia

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

....................................
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Kanan
Parosmia

Kiri

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

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

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

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

V.O.D

V.O.S

- Anopsia

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

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

- Hemianopsia

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

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

- Papil edema

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

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

- Papil atrofi

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

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

- Perdarahan retina

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

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

N.Opticus
Visus
Campus visi

Fundus Oculi

Nn. Occulomotorius, Trochlearis dan Abducens

Kanan

Kiri

Diplopia

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

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

Celah mata

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

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

Ptosis

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

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

- Strabismus

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

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

- Exophtalmus

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

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

- Enophtalmus

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

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

- Deviation conjugae

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

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

Gerakan bola mata

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

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

- Bentuknya

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

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

- Besanya

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

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

- Isokori/anisokor

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

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

- Midriasis/miosis

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

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

Sikap bola mata

Pupil

- Refleks cahaya
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Kanan

Kiri

- Langsung

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

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

- Konsensuil

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

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

- Akomodasi

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

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

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

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

- Argyl Robertson

N.Trigeminus
Kanan

Kiri

Motorik
- Menggigit

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

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

- Trismus

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

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

- Refleks kornea

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

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

- Dahi

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

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

- Pipi

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

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

- Dagu

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

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

Sensorik

N.Facialis

Kanan

Kiri

Motorik
Mengerutkan dahi

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

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

Menutup mata

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

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

Menunjukkan gigi

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

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

Lipatan nasolabialis

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

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

- Istirahat

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

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

- Berbicara/bersiul

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

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

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

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

- Salivasi

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

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

- Lakrimasi

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

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

- Chovsteks sign

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

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

Bentuk Muka

Sensorik
2/3 depan lidah
Otonom

N. Statoacusticus
N. Cochlearis

Kanan

Kiri

Suara bisikan

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

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

Detik arloji

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

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

Tes Weber

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

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

Tes Rinne

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

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

Nistagmus

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

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

Vertigo

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

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

N. Vestibularis

N. Glossopharingeus dan N. Vagus

Arcus pharingeus

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

Uvula

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

Gangguan menelan

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

Suara serak/sengau

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

Denyut jantung

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

Refleks
- Muntah

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

- Batuk

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

- Okulokardiak

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

- Sinus karotikus

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

Sensorik
- 1/3 belakang lidah

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

N. Accessorius
Mengangkat bahu

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

Memutar kepala

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

N. Hypoglossus
Mengulur lidah

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

Fasikulasi

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

Atrofi papil

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

Disartria

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MOTORIK
LENGAN

Kanan

Kiri

Gerakan

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

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

Kekuatan

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

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

Tonus

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

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

Refleks fisiologis

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

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

Refleks patologis
-

Hoffman Trommer

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

Leri

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

Meyer

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

TUNGKAI

Kanan

Kiri

Gerakan

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

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

Kekuatan

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

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

Tonus

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

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

Klonus
-

Paha

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

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

Kaki

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

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

Refleks fisiologis
-

KPR

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

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

APR

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

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

Refleks patologis
-

Babinsky

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

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

Chaddock

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

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

Oppenheim

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

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

Gordon

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

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

Schaeffer

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

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

Rossolimo

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

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

Mendel Bechterew

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

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

Refleks kulit perut

-

Atas

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

Tengah

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

Bawah

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

Refleks cremaster

....................................
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SENSORIK
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GAMBAR

FUNGSI VEGETATIF
Miksi

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

Defekasi

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

KOLUMNA VERTEBRALIS
Kyphosis

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

Lordosis

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

Gibbus

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

Deformitas

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

Tumor

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

Meningocele

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

Hematoma

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

Nyeri ketok

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

GEJALA RANGSANG MENINGEAL

Kanan
Kaku kuduk

Kiri
....................................

Kernig

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

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

Lasseque

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

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

Brudzinsky
-

Neck

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

Cheek

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

Symphisis

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

Leg I

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

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

Leg II

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

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

GAIT DAN KESEIMBANGAN

Gait

Keseimbangan dan Koordinasi

Ataxia

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

Romberg

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

Hemiplegic

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

Dysmetri

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

Scissor

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

- jari-jari

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

Propulsion

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

- jari hidung

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

Histeric

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

- tumit-tumit

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

Limping

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

Rebound phenomen : ....................................

Steppage

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

Dysdiadochokinesis : ....................................

Astasia-Abasia: ....................................

Trunk Ataxia

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

Limb Ataxia

: ....................................
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GERAKAN ABNORMAL
Tremor

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

Chorea

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

Athetosis

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

Ballismus

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

Dystoni

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

Myocloni

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

FUNGSI LUHUR
Afasia motorik

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

Afasia sensorik

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

Apraksia

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

Agrafia

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

Alexia

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

Afasia nominal

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

LABORATORIUM
DARAH
Hb

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

Kolesterol HDL

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

Eritrosit

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

Kolesterol LDL

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

Leukosit

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

Trigliseride

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

Trombosit

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

Total Lipid

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

Diff count

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

Uric Acid

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

Hematokrit

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

Ureum

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

BSS

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

Kretinin

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

BSN/BSPP

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

WR/KAHN/VRDL

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

Warna

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

Sedimen :

Reaksi

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

- Eritrosit

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

Protein

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

- Leukosit

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

Reduksi

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

- Thorak

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

Urobilin

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

- Sel Epitel : ....................................

Bilirubin

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

- Bakteri

URINE

: ..................................
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FAECES
Konsistensi

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

Histolitika

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

Lendir

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

Eritrosit

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

Darah

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

Leukosit

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

Amuba Coli

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

Telur cacing : ....................................

LIQUOR CEREBROSPINALIS
Warna

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

Protein

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

Kejernihan

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

Glukosa

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

Tekanan

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

Nacl

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

Sel

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

Queckensted : ....................................

Nonne

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

Celloidal

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

Pandy

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

Culture

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

PEMERIKSAAN KHUSUS
Rontgen foto cranium

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

Rontgen foto thoraks

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

Rontgen foto vertebralis

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

Electroencephalografi

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

Electroneuromyografi

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

Electrocardiografi

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

Arteriografi

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

Pneumografi

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

CT-Scan

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

Lain-lain

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

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RINGKASAN
ANAMNESA
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PEMERIKSAAN
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DIAGNOSA
DIAGNOSA KLINIK

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DIAGNOSA TOPIK

: ..................................................................................................
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DIAGNOSA ETIOLOGI

: ..................................................................................................
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PENGOBATAN

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PROGNOSA

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