STATUS NEUROLOGI (KSM NEUROLOGI RSUD ABEPURA)

IDENTITAS
Nama : .....................................................................................
Jenis Kelamin : L/P
Umur : ........ Tahun
Alamat : Islam/KP/KK/Hindu/Budha
Pekerjaan : .....................................................................................
Status : Lajang/Menikah/Cerai/Duda/Janda
No. RM :__ __ __
MRS Tanggal :___/___/2018

ANAMNESA
Keluhan Utama : ...............................................................................................................................
Riwayat Penyakit Sekarang :.............................................................................................................
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Riwayat Penyakit Dahulu : ...............................................................................................................
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Riwayat Penyakit Keluarga : ............................................................................................................
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Sosial/Ekonomi/Kebiasaan : .............................................................................................................
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PEMERIKSAAN FISIK
Status generalis → KU : .....................................................
Kes : ......................................................
Pupil : ......................................................

TD : ___/___mmhg MABP = ____ N : ____x/mnt

(kuat angkat/tidak kuat angkat
RR : ___x/menit reguler/ireguler)
SpO2 : ___x/menit SB : ___ oC

Mata/Wajah/Kulit : ………………………………………………………………………..
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Telinga/Hidung/Tenggorok : ………………………………………………………………………..
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Leher/Thorax : ………………………………………………………………………..
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Jantung/Paru : ………………………………………………………………………..
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Abdomen : ………………………………………………………………………..
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Ekstremitas : ………………………………………………………………………..
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Genitalia : ………………………………………………………………………..
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Coass : ..................................................... Page 1

Status Neurologis → GCS : E__M__V__ ( )
TRM → KK : ................ Laseque : ......../......... Kerniq : ................

Nervus Cranial :
I .............................................
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III .............................................
IV .............................................
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VII .............................................
VIII .............................................
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X .............................................
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XII .............................................

Motorik → Kekuatan otot : Tonus Otot :

RF : Bisep ......../......... Trisep ......../........ Patella ......../........ Achilles......../........

RP : Hoffman-Trommer ......../........ Babinsky ......../........ Oppenheim......../........

PEMERIKSAAN PENUNJANG
Laboratorium :

Radiologi :
Siriraj Score :
Algoritma Gadjah Mada :

DIAGNOSA
Klinis : ....................................................................................................................
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Topis : ....................................................................................................................
Etiologis : ....................................................................................................................
Patologi : ....................................................................................................................
Diagnosa lain : ....................................................................................................................
Diagnosis Banding : ....................................................................................................................

TATALAKSANA

PROGNOSA
Ad Vitam :
Ad Functionam :
Ad Sanactionam :

Coass : ..................................................... Page 2