LEMBAR STATUS PASIEN

DEPARTEMEN RAHABILITASI MEDIK RS YOWARI- KAB. JAYAPURA

I. DATA DASAR
1.1 Identitas
Nama : Agama:
Jeniskelamin : suku:
Usia : Pekerjaan:
Alamat : Pendidikan:
Status pernikahan : Rujuakan dari:
No. Rekam Medik No. BPJS:
No. Jamkespa : No. Jamkesmas:

Anamnesis

1.1.1 Keluhan utama :

1.1.2 Riwayat penyakit sekarang (Tanggal………….)

1.1.3 Riwayat penyakit dahulu:

1.1.4 Riwayat sosial ekonomi:

1.2 Pemeriksaan fisik
1.2.1 General status
 Compos mentis ● bed ridden ● right handed ● Ambulasi………
 GCS : Mata 4,3,2,1 ; Bicara 5,4,3,2,1 ; Motorik 6,5,4,3,2,1 :………… (456)
 Vital sign : BP mmHg; HR x/min; RR x/min; temp °C
 BMI: < 18,5 (normal); 18,5-24,9 moderate; 25-29,9 over weight; > 30 Obesitas 23
(BB/TB²)
1.2.2 Kepala & leher : Anemia….,Icterus….., Cyanosis…., dypsneu…..

Thorax: Heart : Suara S1S2 ……………., murmur……………..

Lung(Paru) : Vesicular……… .. ; ronchi …………………… ; Wheezing ……………

Gambar:

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Abdomen : Supple………. , meteorismus ………, hepar & lien tak teraba / teraba

Extremities (AGA/AGB) : Acral hangat/dingin, oedema +/- at , Fraktur: + / -

Gambar :

1.3 Physiatric examination

1.3.1 Musculoskeletal Status

Cervical ROM MMT (0,1,2,3,4,5)

Flexion F(0⁰-40⁰) (5)

Extension F(0⁰-40⁰) (5)

Lateral flexion F/F(0⁰-45⁰)

(5/5)

Rotation F/F(0⁰-50⁰)
(5/5)

Trunk ROM MMT

Flexion F(0⁰-85⁰) (5)

Extension F(0⁰-30⁰) (5)

Lateral Flexion F/F(0⁰-30⁰) (5/5)

Rotation F/F(0⁰-45⁰) (5/5)

Shoulder ROM MMT

Flexion F/F(0⁰-180⁰) (5/5)

Extension F/F(0⁰-80⁰) (5/5)

Abduction F/F(0⁰-180⁰) (5/5)

Adduction F/F(0⁰-45⁰) (5/5)

Ext.Rotasion F/F(0⁰-70⁰) (5/5)

Int.Rotasion F/F(0⁰-90⁰) (5/5)

Elbow ROM MMT

Flexion-Extension F/F(0⁰-135⁰) (5/5)

Forearm supination F/F(0⁰-90⁰) (5/5)

Forearm Pronation F/F(0⁰-90⁰) (5/5)

Wrist ROM MMT

Flexion F/F(0⁰-60⁰) (5/5)

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Extension F/F(0⁰-70⁰) (5/5)

Radial deviation F/F(0⁰-20⁰) (5/5)

Ulnar deviation F/F(0⁰-30⁰) (5/5)

Fingers ROM MMT

Flexion Full/Full (5/5)

Extension Full/Full (5/5)

Abduction Full/Full (5/5)

Adduction Full/Full (5/5)

Hip ROM MMT

Flexion F/F(0⁰-125⁰) (5/5)

Extension F/F(0⁰-15⁰) (5/5)

Abduction F/F(0⁰-45⁰) (5/5)

Adduction F/F(0⁰-25⁰) (5/5)

Ext.. Rotation F/F(0⁰-45⁰) (5/5)

Int.Rotation F/F(0⁰- 40⁰) (5/5)

Knee ROM MMT

Flexion F/F(0⁰-130⁰) (5/5)

Extension F/F(130⁰-0⁰) (5/5)

Ankle ROM MMT

Plantar Flexion F/F(0⁰-50⁰) (5/5)

Dorso Flexion F/F(0⁰-20⁰) (5/5)

Inversion F/F(0-35⁰) (5/5)

Eversion F/F(0-15⁰) (5/5)

Toes ROM MMT

Flexion Full/Full (5/5)

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Extension Full//Full (5/5)

Big Toe ROM MMT

Flexion Full/Full (5/5)

Extension Full/Full (5/5)

1.4.2 Neurological Status

• Nervus Kranialis I-XII :

N. I (Olfaktorius-sensoris)

N.II (Optikus-Sensoris)

N.III(Oculomotorius-Motorik)

N.IV(Trochlearis-mata: (M.Obliq
sup)

N.V(Trigeminus-sensoris wajah) Cab 1. Opthalmikus

Cab 2. Maxilaris

Cab 3. Mandibularis

Dan M. Masticator Mengunyah…………………

N.VI(Abducens-mata :M.ext,
rectus)

N.VII(Fasialis – motorik wajah) Central/perifer tipe;

Sensoris : Ant lidah & palatum Rasa manis….., asin…., asam…, pahit…..

N.VIII(Akustikus-pendengaran)

N.IX(Glosopharingeus) Gag reflex +/-……..; central.perifer tipe;

N.X(Vagus)

N.XI(Assesorius) M.Sternocleidomastoideus

M.Trapezius

N.XII(Hypoglosus) Gerakan otot lidah……………..

• Deep tendon reflexes : BPR (+2/+2) PR (+2/+2)

KPR (+2/+2) APR (+2/+2)

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• Reflek patologi : Babinski ……….., Chadok………..Openheim…………

Hoffman …………., Tromner…………

•Tonus otot : Spastik AGA(UE) ……………. ,AGB( LE) …………….

Ashworth Spasticity scale : 0, 1, 1+, 2, 3, 4

• Sensory :

Exteroceptive : Suhu , Nyeri (ujung jarum) (N/N)

Proprioceptive : Tekan , Joint position: AGA AGB (N/N)

Extinction phenomenon ; (N/N)

Two point discrimination : normal/normal (N/N)

Gambar lokasi patologis:

• Pemeriksaan fungsi Cerebellum :

Coordination : Disdiadokokinesia ……. , finger to nose …….. , disatria + / -

Balance : Truncal ataxia: Duduk + / -,Berdiri ; standing by him self + / -

• Shoulder subluxation: + / -

• Hand function (fungsi tangan):

Power Graps : Graps Prehension : Memegang hammer

/mengepal dg kuat

Cylindrical Memegang hammer, raket, botol

Spherical Memegang buah apel, knob pintu,

angkat gelas dari bag. atas, buka tutup
botol mulut lebar.

Hook Mengangkat koper, keranjang

Precision Pegang dg ujung jari tangan (pena,

menyulam dg jarum, mengancing baju)

• Higher function status :

- Attention and concentration : ……………………………………..(N)

Bahasa : Naming….., fluent…., comprehensive….., repetition…… :

(N)
- Perceptual : Spatial neglect : -
Alexia(baca)……………(baik); Apraxia(ikut
perintah)……….(baik); Agraphia(menulis)……….. (baik); acalculia
(menghitung)……….(baik);
- Memory : Short term memory : ……………………………….(baik)
Long term memory : ……………………………….(baik)

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 Orientation : ………………………………………..(baik)
1.3.2 Barthel Index
Feeding(makan) Bladder (BAK)

Toilet use
Bathing (mandi) (menggunakan WC)
Transfer (Berpindah
Grooming(wanita: merias, tempat tanpa jarak)
laki: bercukur)
Mobility(berpindah
Dressing(berpakaian) tempat dg jarak)
Stairs(naik tangga)
Bowel(BAB)

Total

Supporting Examination

1.3.3 Laboratory examination (tanggal…….)

HB : g/dl Glukosa 2 JPP mg/dl
Glukosa Puasa mg/dl
Leukosit: /L
Glukosa Acak mg/dl
HCT %
Albumin g/dl
Platelet g/dl
Kalium mEq/l
Thrombosit g/dl
Kolesterol total mg/dl

1.3.3 Pemeriksaan Radiologi

Head CT Scan (tgl:……….): Kesimpulan:

Chest-xray (Tgl………): Kesimpulan:

Bone Xray lain (tgl…….) :Kesimpulan:

USG (Tgl……): Kesimpulan:

MRI (Tgl…….): Kesimpulan:

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1.3.4 Konsultasi:
Departemen (Tgl) Kesimpulan Saran

B. Orthopedi/Lain

Neurologi

Pediatri

Kardiologi

Pulmonologi

Interna

Kulit Kelamin

Obsgyn

ICU

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 II. DIAGNOSA
2.1 Diagnosis :

2.2 Diagnosis fungsi :

●Impairment :

●Disability :

●Handicap :

III. PROBLEM LIST

3.1 Medical :
3.2 Surgical:
3.3 Rehabilitation Medicine :
R1 (Ambulation)
R2 (ADL)
R3 (communication)
R4 (Psychological)
R5 (Social Economy)
R6 (Vocational)
: ………………………….
: Bartel index ……………..
: ……………………………..
:……………………………...
: (Jamkesmas)
: (pekerjaan px)

R7 (Others) :

Tujuan penatalaksanaan terapi :

a. Immediate goals :

b. Ultimate goals :

IV. MANAGEMENT
4.1 Medical problem :
P.Diagnosa :

P.Terapi :

PMonitoring:
4.2 Surgical problem : -
P.Diagnosa :

P.Terapi :

PMonitoring:
4.3 Rehabilitation Medicine problem :
 R1 (Ambulation) :
P.Diagnosa :
P.Terapi:
P.Monitoring : bartel index…….GCS………, VS..……, MMT……
neurological status
P.Edukasi :

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 R2 (ADL) : Bartel index
PDx : -
PTx :
PMx : Barthel index……..GCS……..VS……MMT……..neurologi status………
PEx :
 R3 (Communication) :
PDx:-
PTx:
PMx:
PEx:
 R4 (Psychological) :
PDx : -
PTx :
PMx :
PEx :
 R5 (Social Economic):
PDx :
PTx:
PMx : -
PEx :
 R6 (Vocational) :
PDx: -
PTx :
PMx : Bartel Index……,GCS………,VS………..MMT……Neurologi status……….
PEx :
• R7 (Others) :
PDx :
PTx:
PMx : Bartel Index……,GCS………,VS………..MMT……Neurologi status……….
PEx :