FK UNSRI PALEMBANG

RM.R

BAGIAN REHABILITASI MEDIK

ANAMNESIS

Ruang :..

Alamat

Nama :..
:.

Pekerjaan

Tanggal pemeriksaan :.

No.Rek.Med :
Umur / Jenis : L / P
Agama
:
Status perkawinan :
Dokter muda

1. ANAMNESIS
2. KELUHAN UTAMA
.
3. RIWAYAT PENYAKIT SEKARANG
.
.
.
.
.
.
.
.
.
4. RIWAYAT PENYAKIT / OPERASI DAHULU
.
.
.
.
.
.
5. RIWAYAT PENYAKIT PADA KELUARGA
.
.
.

6. RIWAYAT PEKERJAAN

7. RIWAYAT SOSIAL EKONOMI

.

FK UNSRI PALEMBANG

RM.R

BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK

Ruang :
Nama :

No.Rek.Med :
Umur :

L / P

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

Nadi

x / menit

Pernafasan

x / menit

Suhu

Kulit

mmHg

Status Psikis
Sikap

Orientasi

Ekspresi wajah

Perhatian :........................................

PEMERIKSAAN FISIK

Ruang :

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

No.Rek.Med :

FK UNSRI PALEMBANG

RM.R

BAGIAN REHABILITASI MEDIK

Nama :

Umur

L / P

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 :

FK UNSRI PALEMBANG

RM.R

BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK

Ruang :
Nama :

D. Leher
Inspeksi

No.Rek.Med :
Umur :

L / P

Palpasi

: ..

Luas Gerak Sendi

Ante / retrofleksi

( n 65 / 50 ) : /.

Laterofleksi ( D/S )

( n 40 / 40 ) :/.

Rotasi

( n 45 / 45 ) : /..

( D/S )

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

PEMERIKSAAN FISIK

Ruang :

No.Rek.Med :

FK UNSRI PALEMBANG

RM.R

BAGIAN REHABILITASI MEDIK

Nama :

Umur

L / P

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

FNST

:../.Test Patrick :. /.Test Kontra Patrick

:/

Test Gaenslen

:../.Test Thomas:. /. Test Obers

:/

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

:./..

Yeomans hyprextension :../.. Mc.Bridge toe to mouth sitting test

;./..

Test Schober

:./. Test: OConnell

:./

H. Anggota Gerak Atas

Inspeksi

kanan

kiri

Deformitas

Edema

Tremor

Nodus heberden

No.Rek.Med :

Palpasi

Ruang :

FK UNSRI PALEMBANG

RM.R

BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK /
NEUROLOGI

Nama :

Umur

L / P

Neurologi
Motorik

Dextra

Sinistra

Gerakan

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

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

Kekuatan

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

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

Abduksi lengan

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

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

Fleksi siku

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

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

Ekstensi siku

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

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

Ekstensi Wrist

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

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

Fleksi jari- jari tangan

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

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

Abduksi jari tangan

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

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

Tonus

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

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

Tropi

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

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

Refleks tendon biseps

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

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

Refleks tendon triseps

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

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

Hoffman

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

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

Tromner

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

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

Refleks Fisiologis

Refleks Patologis

Sensorik
Protopatik

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

Proprioseptik

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

Vegetatif
Penilaian fungsi tangan

:....................................................................................................................
kanan

kiri

Anatomical

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

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

Grips

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

...

Spread

...

Palmar abduct

Pinch

....

Lumbrical

.....

FK UNSRI PALEMBANG

RM.R

BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK / LGS

Luas gerak sendi

Ruang :
Nama :

No.Rek.Med :
Umur :

Aktif
Dexra

Aktif
sinistra

Pasif
Dexra

L / P
Pasif
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

FK UNSRI PALEMBANG

RM.R

BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK

Ruang :
Nama :

No.Rek.Med :
Umur :

L / P

I. Anggota Gerak Bawah

Inspeksi

kanan

kiri

Deformitas

..

Edema

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

Tremor

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

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

Palpasi
-

Nyeri tekan ( lokasi ) :

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

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

Diskrepansi

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

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

Neurologi
Motorik

kanan

kiri

...........

...........

Fleksi paha

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

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

Ekstensi paha

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

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

Ekstensi lutut

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

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

Fleksi lutut

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

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

Dorsofleksi pergelangan kaki

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

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

Dorsofleksi ibu jari kaki

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

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

Plantar fleksi pergelangan kaki

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

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

Tonus

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

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

Tropi

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

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

Refleks tendo patella

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

...

Refleks tendo achilles

..

Babinsky

Chaddock

Gerakan
Kekuatan

Refleks Fisiologis

Refleks patologi

FK UNSRI PALEMBANG

RM.R

BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK / LGS

Ruang :
Nama :

Sensorik

No.Rek.Med :
Umur :
kanan

L / P

kiri

- Protopatik

- Proprioseptik

Vegetatif
Luas gerak sendi
Luas gerak
Sendi

Aktif
Dextra

Aktif
Sinistra

Pasif
Dextra

Pasif
Sinistra

Fleksi paha

..

Ekstensi paha

..

Endorotasi

..

Adduksi paha

..

Abduksi paha

..

Fleksi lutut

..

Ekstensi lutut

..

Dorsofleksi pergelangan kaki

Plantar fleksi pergelangan kaki

Inversi kaki

Eversi kaki

paha

Test Provokasi sendi lutut

kanan

kiri

Stres test

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

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

Drawers test

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

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

Test Tunel pada sendi lutut

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

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

Test Homan

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

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

Test lain lain

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

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

FK UNSRI PALEMBANG

RM.R

10

BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK

Ruang :
Nama :

No.Rek.Med :
Umur :

L / P

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 :

..

FK UNSRI PALEMBANG

RM.R

11

BAGIAN REHABILITASI MEDIK

RESUME

Ruang :
Nama :

No.Rek.Med :
Umur :

L / P

V. RESUME

....

....
...
....

...

...

...

...
...
...

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

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

FK UNSRI PALEMBANG

RM.R

12

BAGIAN REHABILITASI MEDIK

EVALUASI / DIAGNOSIS

Ruang :
Nama :

No.Rek.Med :
Umur :

L / P

VI. EVALUASI
NO
1

Level ICF
Struktur dan fungsi tubuh

Aktivitas

Partisipasi

Catatn : ICF

Kondisi saat ini

..

..
..
..
..
..

Sasaran
..

..
..
..
..

..

..
..

..
..

International Clasification of Function ( WHO 2002 )

DIAGNOSIS KLINIS
.....................................................................................................................................................................
.....................................................................................................................................................................

FK UNSRI PALEMBANG

RM.R

13

BAGIAN REHABILITASI MEDIK

PROGRAM REHABILITASI

Ruang :
Nama :

No.Rek.Med :
Umur :

L / P

VII. PROGRAM REHABILITASI MEDIK

Fisioterapi
Terapi panas

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

Terapi dingin

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

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

..............................................................................................................
Terapi latihan : .............................................................................................................
.............................................................................................................
Okupasi terapi
ROM

excercise

ADL Excercise
Ortotik prostetik
Ortotic

:
:

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

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

Prostetic

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

Alat bantu ambulasi

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

Terapi wicara
Afasia
Dysartria
Dysfagia

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

Social medik

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

Edukasi

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

FK UNSRI PALEMBANG

RM.R

14

BAGIAN REHABILITASI MEDIK

TERAPI
PROGNOSA / FOLLOW UP

Ruang :
Nama :

No.Rek.Med :
Umur :

L / P

VIII. TERAPI MEDIKAMENTOSA

.

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

IX . PROGNOSA
Mmmm -

Medik

Fungsional

:.

X . FOLLOW UP
Tanggal

:.

Keluhan

: .

Pemeriksaan Umum

: .

Keadaan khusus

: .

Fungsional

: Barthel Index

FIM Index

Katz index