Status Ujian
Status Ujian
UNSRI PALEMBANG
RM. R
BAGIAN REHABILITASI MEDIK
ANAMNESIS
RUA
NG
: ...................
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No. REK.
MED
: ........................
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NAM
A
: ...................
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UMUR / JK
: ..............
L/P
AGAMA
: ........................
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thn /
ALAMAT
: ..............................
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PEKERJAAN
: ..............................
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STATUS
PERKAWIN
AN
: ........................
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TGL.
PEMERIKSAAN
: ..............................
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Dokter
Muda
: ........................
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I. ANAMNESIS
1. KELUHAN UTAMA
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2. RIWAYAT PENYAKIT SEKARANG
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3. RIWAYAT PENYAKIT / OPERASI DAHULU
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RM. R
BAGIAN REHABILITASI MEDIK
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4. RIWAYAT PENYAKIT PADA KELUARGA
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5. RIWAYAT PEKERJAAN
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6. RIWAYAT SOSIAL EKONOMI
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PEMERIKSAA
N
FISIK
RUA
NG
: ........................
........
NO. MED.
REK
: .........................
.........
NAM
A
: ........................
.........
Umur /
JK
II. PEMERIKSAAN
FISIK
A. PEMERIKSAAN UMUM
Keadaan Umum
Kesadaran
: G
...............
cm / ................
kg
: ...............
gait
..............
Antalgik
: ..............................................................................
RM. R
BAGIAN REHABILITASI MEDIK
Hemiparese
gait
: ....................................................................................
........
Steppage
gait
: ................................................................................
............
Parkinson
gait
: .................................................................................
...........
Tredelenberg
gait
: ......................................................................................
......
Waddle
gait
: .............................................................................
...............
Lain -
lain
: ..........................................................................
..................
Bahasa / Bicara
Komunikasi
verbal
: .................................................................................
...........
Komunikasi
nonverbal
: ..................................................................................
..........
Tanda Vital
Tekanan darah
Nadi
Pernafasan
Suhu
:
:
:
:
Kulit
Status
Psikis
Sikap
mmHg
x /
x
o
menit
/ menit
RM. R
BAGIAN REHABILITASI MEDIK
Orientasi
: ...........................
Ekspresi
wajah
Perhatian : ...........................
Ekspresi
PEMERIKSAA
N
FISIK
wajah
RUA
NG
: ........................
........
NO. MED.
REK
: .........................
........
NAM
A
: ........................
........
Umur /
JK
Kanan
Kiri
I.
N. Olfaktorius
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II.
N. Opticus
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III.
N. Occulomotorius
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IV.
N. Trochlearis
.................
.................
V.
N. Trigeminus
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VI.
N. Abducens
.................
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VII. N. Fascialis
.................
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VIII. N. Vestibularis
.................
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IX. N. Glossopharyngeus
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.................
X. N. Vagus
.................
.................
RM. R
BAGIAN REHABILITASI MEDIK
XI. N. Accesorius
.................
.................
XII. N. Hypoglosus
.................
.................
C. Kepala
Bentuk
: .....................................................................
.......................................
Ukuran
: .....................................................................
.......................................
Posisi
Mata
: ...............................................................................
.............................
Hidung
: ...............................................................................
.............................
Telinga
: ...............................................................................
.............................
Mulut
: ...............................................................................
.............................
Wajah
: simetris / asimetris
Gerakan
abnormal : .....................................................................................
.......................
PEMERIKSAA
N
FISIK
RUA
NG
: ........................
........
NO. MED.
REK
: .........................
........
RM. R
BAGIAN REHABILITASI MEDIK
NAM
A
: ........................
........
Umur /
JK
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 Valsava
..................
Distraksi test
Test Nafziger :
: ................
: ................
...................
E. Thorak
Bentuk
: .............................................................
.......................................
Pemeriksaan Ekspansi Thorak : Ekspirasi Maksimum ...... cm.
Inspirasi maksimum ..... cm
Paru Paru
Inspeksi
: ..........................................................................
.........................
Palpasi
.........................
: ..........................................................................
RM. R
BAGIAN REHABILITASI MEDIK
Perkusi
: ..........................................................................
.........................
Auskultasi
: ............................................................................
........................
Jantung
Inspeksi
: ...........................................................................
........................
Palpasi
: ...........................................................................
........................
Perkusi
: ..........................................................................
.........................
Auskultasi
: ............................................................................
.......................
Abdomen
Inspeksi
: .............................................................................
.......................
Palpasi
: .............................................................................
.......................
Perkusi
: ............................................................................
........................
Auskultasi
: .............................................................................
........................
PEMERIKSAA
N
RUA
: ........................
NO. MED.
: .........................
RM. R
BAGIAN REHABILITASI MEDIK
NG
FISIK
NAM
A
........
REK
: ........................
........
Umur /
JK
........
: ............ .... thn
/ L/P
G. Trunkus
Inspeksi
: Simetris
Deformitas
........................................................................................
..............................
Lordosis
.......................................................................................
...............................
Scoliosis
.......................................................................................
...............................
Gibbus
: ........................................................................................
..............................
Hairy
spot
: ..................................................................................................
....................
Pelvic
Tilt
: ..................................................................................................
....................
Palpasi
: ............................................................................
Nyeri tekan
( lokasi )
: ...............................................................
............
Luas
Ante / Retrofleksi ( 95 /
35 )
: ............................................................................
Laterofleksi ( D / S ) ( 40 /
RM. R
BAGIAN REHABILITASI MEDIK
40 )
: ............................................................................
Rotasi ( D / S ) ( 35 /
35 )
: ............................................................................
Test provokasi
Valsava test
: .................
Test SLR
: ....... / ......
FNST
: ........ / ........
: ...... / .......
: ...... / .......
: ....... / ......
Yeomann s hyprextension
: ........ / .........
PEMERIKSAA
N
FISIK /
NEUROLOGI
Kanan
:
.......................
.......................
.......................
.......................
RUA
NG
: ........................
........
NO. MED.
REK
: .........................
........
NAM
A
: ........................
........
Umur /
JK
RM. R
BAGIAN REHABILITASI MEDIK
Neurologi
Motorik
Dextra
Sinistra
Gerakan
...................
...................
Kekuatan
...................
...................
Abduksi lengan
...................
Fleksi bahu
...................
Ekstensi siku
...................
...................
...................
...................
...................
...................
Tonus
...................
...................
Tropi
...................
...................
Refleks fisiologis
Refleks tendon bisep
...................
...................
...................
...................
Refleks patologis
Hoffman
...................
Tromner
...................
...................
...................
Sensorik
Protopatik
...................
...................
Proprioseptik
...................
...................
RM. R
BAGIAN REHABILITASI MEDIK
Vegetatif
...................
...................
Penilaian fungsi tangan
Dextra
Sinistra
Anatomical
...................
...................
Grips
...................
...................
Spread
...................
...................
Palmar abduct
...................
...................
Pinch
...................
...................
Lumbrical
...................
...................
PEMERIKSAA
N
FISIK / LGS
RUA
NG
: ........................
........
NO. MED.
REK
: .........................
........
NAM
A
: ........................
........
Umur /
JK
RM. R
BAGIAN REHABILITASI MEDIK
Aktif
Aktif
Pasif
Pasif
Abduksi bahu
Dextra
...............
Sinistra
...............
Dextra
...............
Sinistra
...............
Adduksi bahu
.
...............
...............
.
...............
...............
Fleksi bahu
.
...............
...............
.
...............
...............
Ekstensi bahu
.
...............
...............
.
...............
...............
Endorotasi bahu
( f0 )
.
...............
...............
.
...............
...............
Eksorotasi bahu
( f0 )
.
...............
...............
.
...............
...............
Endorotasi bahu
( f90 )
Eksorotasi bahu
( f90 )
Fleksi siku
...............
...............
...............
...............
Ekstensi siku
.
...............
...............
.
...............
...............
.
...............
...............
.
...............
...............
.
...............
...............
.
...............
...............
Supinasi
.
...............
...............
.
...............
...............
Pronasi
.
...............
...............
.
...............
...............
.
Test Provokasi
.
Kanan
Kiri
Yergason test
...............
...............
...............
...............
Moseley test
...............
...............
Adson manuver
...............
...............
Tinel test
...............
...............
Phalen test
...............
...............
Prayer test
...............
...............
Finkelstein
...............
...............
Promet test
...............
...............
RM. R
BAGIAN REHABILITASI MEDIK
PEMERIKSAA
N
FISIK
RUA
NG
: ........................
........
NO. MED.
REK
: .........................
........
NAM
A
: ........................
........
Umur /
JK
RM. R
BAGIAN REHABILITASI MEDIK
I.
Anggota Gerak Bawah
Inspeksi
- Deformitas
- Edema
- Tremor
Palpasi
- Nyeri tekan ( lokasi )
- Diskrepansi
Neurologi
Motorik
Gerakan
Kekuatan
Fleksi paha
Ekstensi paha
Ekstensi lutut
Fleksi lutut
Dorsofleksi pergelangan
Kanan
...................
...................
...................
...................
...................
...................
Kiri
..................
..................
..................
..................
..................
..................
Kanan
...................
Kiri
..................
...................
...................
...................
...................
...................
..................
..................
..................
..................
..................
...................
..................
Plantar fleksi
...................
..................
...................
...................
..................
..................
...................
..................
...................
..................
...................
...................
..................
..................
:
:
:
:
:
kaki
kaki
pergelangan tangan
Tonus
Tropi
Reflkes fisiologis
Refleks tendo
patella
Refleks tendo achilles
Refleks patologi
Babinsky
Chaddock
PEMERIKSAA
N
FISIK / LGS
RUA
NG
: ........................
........
NO. MED.
REK
: .........................
........
NAM
A
: ........................
........
Umur /
JK
RM. R
BAGIAN REHABILITASI MEDIK
Sensorik
Protopatik
Proprioseptik
Vegetatif
Kanan
................
................
................
Kiri
................
................
................
Aktif
Aktif
Pasif
Pasif
Fleksi paha
Dextra
.............
Sinistra
.............
Dextra
.............
Sinistra
.............
Ekstensi paha
...
.............
...
.............
...
.............
...
.............
Endorotasi paha
...
.............
...
.............
...
.............
...
.............
Adduksi paha
...
.............
...
.............
...
.............
...
.............
Abduksi paha
...
.............
...
.............
...
.............
...
.............
Fleksi lutut
...
.............
...
.............
...
.............
...
.............
Ekstensi lutut
...
.............
...
.............
...
.............
...
.............
...
.............
...
.............
...
.............
...
.............
...
.............
...
.............
...
.............
...
.............
Inversi kaki
...
.............
...
.............
...
.............
...
.............
Eversi kaki
...
.............
...
.............
...
.............
...
.............
...
...
...
...
Test Provokasi
Stres test
Drawers test
Test tunel pada sendi lutut
Test homan
Test lain lain
PEMERIKSAA
N
FISIK
RUA
NG
Kanan
................
................
................
................
................
: ........................
........
NO. MED.
REK
Kiri
................
................
................
................
................
: .........................
........
RM. R
BAGIAN REHABILITASI MEDIK
NAM
A
: ........................
........
Umur /
JK
: .......................................................................
Reaksi keseimbangan
........
: .......................................................................
Pemeriksaan lainnya
........
: .......................................................................
........
Sensorik perianal
: .......................................................................
........
: .......................................................................
eksternus
BCR ( Bulbocapernosis
........
: .......................................................................
Refleks )
Fungsi luhur
-
........
Afasia
: .......................................................................
Apraksia
........
: .......................................................................
Agrafia
........
: .......................................................................
Alexia
........
: .......................................................................
........
.......................................................................................................................
..............................
.......................................................................................................................
..............................
B. LABORATORIUM
.......................................................................................................................
..............................
.......................................................................................................................
..............................
RM. R
BAGIAN REHABILITASI MEDIK
MRI
.......................................................................................................................
..............................
.......................................................................................................................
..............................
RESUME
RUA
NG
: ........................
........
NO. MED.
REK
: .........................
........
NAM
A
: ........................
........
Umur /
JK
RM. R
BAGIAN REHABILITASI MEDIK
V. RESUME
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RM. R
BAGIAN REHABILITASI MEDIK
.................................
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.................................
EVALUASI /
DIAGNOSIS
VI.
EVALUASI
RUA
NG
: ........................
........
NO. MED.
REK
: .........................
........
NAM
A
: ........................
........
Umur /
JK
RM. R
BAGIAN REHABILITASI MEDIK
N
O
1
Level ICF
Sasaran
.....................................
.....................................
tubuh
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Aktivitas
Partisipasi
RM. R
BAGIAN REHABILITASI MEDIK
.....................................
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Catatan : ICF ( International Clasification of Function / WH0 2002 )
DIAGNOSIS KLINIS
.....................................................................................................................................
................................
.....................................................................................................................................
................................
PEMERIKSAA
N
FISIK
RUA
NG
: ........................
........
NO. MED.
REK
: .........................
........
NAM
A
: ........................
........
Umur /
JK
RM. R
BAGIAN REHABILITASI MEDIK
:
.....................................................................................
......................
.....................................................................................
......................
Stimulasi listrik
:
.....................................................................................
.....................
.....................................................................................
.....................
Terapi latihan
.....................................................................................
.....................
.....................................................................................
.....................
Okupasi Terapi
:
ROM exercise
.....................................................................................
......................
:
ADL exercise
Ortotik Prostetik
Ortotic
.....................................................................................
......................
:
.....................................................................................
......................
Prostetic
:
.....................................................................................
......................
Alat bantu
ambulasi
Terapi wicara
Afasia
:
.....................................................................................
......................
:
.....................................................................................
......................
Dysartria
:
.....................................................................................
......................
RM. R
BAGIAN REHABILITASI MEDIK
Dysfagia
:
.....................................................................................
......................
Social Medik
.....................................................................................
......................
Edukasi
.....................................................................................
......................
PEMERIKSAA
N
FISIK
RUA
NG
: ........................
........
NO. MED.
REK
: .........................
........
NAM
A
: ........................
........
Umur /
JK
RM. R
BAGIAN REHABILITASI MEDIK
: ...........................................................................................................
................
Fungsional
: ...........................................................................................................
RM. R
BAGIAN REHABILITASI MEDIK
................
X. FOLLOW UP
Tanggal
: ...........................................................................................................
...............
Keluhan
: ............................................................................................................
..............
Pemeriksaan
umum
: .........................................................................................................
Keadaan
khusus
: .........................................................................................................
Fungsional
Barthel index
FIM index
Katz index