STATUS KEPANITRAAN KLINIK

BAGIAN ILMU PENYAKIT SARAF

RSU. ROYAL PRIMA MEDAN

STATUS ORANG SAKIT

IDENTITAS
Nama : .........................................................................................................
Umur : .........................................................................................................
Jenis Kelamin : .........................................................................................................
Pekerjaan : .........................................................................................................
Alamat : .........................................................................................................
No. Rekam Medis : .........................................................................................................
Tgl. Masuk RS : .........................................................................................................

ANAMNESIS
Keluhan Utama : .........................................................................................................
Telaah : .........................................................................................................
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RPT : .........................................................................................................
RPO : .........................................................................................................
Riwayat Alergi : .........................................................................................................
Riwayat Keluarga : .........................................................................................................
STATUS PRESENT
Sensorium : ..............................................................................................................
Tekanan Darah : ................mmHg
Frekuensi Nadi : ................x/ menit
Frekuensi Nafas : ................x/ menit
Temperatur : ................oC

STATUS NEUROLOGI
Tanda Rangsang Meningeal : Kaku Kuduk ( )
Brudzinski I ( )
Laseque ( )
Kernig ( )
Brudzinski II ( )

Pemeriksaan Nervus Cranialis

N. I : Normosmia ( / ) Hiposmia ( / ) Hiperosmia ( / )
Parosmia ( / ) Kakosmia ( / )

N. II : Refleks Pupil
Direk ( / )
Indirek ( / )
Test Konfrontasi ( / )

N. III, IV, VI : Gerakan Bola Mata ( )

Ptosis ( )
Doll’s Eye Phenomenon ( )

N. V : Sensorik
N. Ofthalmikus ( )
N. Maksilaris ( )
N. Mandibularis ( )
Motorik
Refleks Kornea ( )
Refleks Masseter ( )
N. VII : Sensorik
2/3 anterior lidah ( )
Motorik
Kerut Kening ( / )
Mengangkat Alis ( / )
Menutup Mata ( / )
Menyeringai ( / )

N. VIII : Keseimbangan ( )
Nistagmus ( )
Test Romberg ( )
Pendengaran ( )

N. IX, X : Refleks Menelan ( )

Refleks Batuk ( )
Gerakan Palatum ( )
Gerakan Uvula ( )

N. XI : Kekuatan m. sternokleidomastoideus ( )
Kekuatan m. trapezius ( )

N. XII : Menjulurkan Lidah ( )

Menggerakkan ke Lateral ( )
Tremor Lidah ( )
Atropi ( )

Pemeriksaan Motorik
Refleks : Refleks Fisiologis : Normal ( + / + )
Anggota Gerak Atas
Bisep ( / )
Trisep ( / )
Brachioradialis ( / )
Anggota Gerak Bawah
APR ( / )
KPR ( / )
 Refleks Patologis : Normal ( - / - )
Babinski ( / )
Chadock ( / )
Openheim ( / )
Gordon ( / )
Gonda ( / )
Schaefer ( / )
Hoffman ( / )
Tromner ( / )

Kekuatan Otot
Ekstremitas Superior Sinistra
Ekstremitas Inferior Sinistra

Ekstremitas Superior Dextra

Ekstremitas Inferior Dextra

Tonus Otot
Hipotonia : .............................................................................................
Hipertonia : .............................................................................................

Sensibilitas : Nyeri : ............................................................................................................

Raba : ............................................................................................................
Getar : ............................................................................................................
Suhu : ............................................................................................................

Sistem Ekstra Piramidal : Tremor : .............................................................................

Korea : .............................................................................
TICS : .............................................................................
Fasikulasa : .............................................................................
Myoclonic Jersk : .............................................................................
Atetosis : .............................................................................
Asterixis : .............................................................................
Balismus : .............................................................................
Tardive Dyskinesia : .............................................................................
Sistem Koordinasi : Test Romberg ( )
Tandem Walking ( )
Finger to Nose ( )
Finger to Nose Finger ( )
Nose Finger Nose Test ( )

Fungsi Kortikal : Atensi/ Konsentrasi ( )

Orientasi ( )
Kecerdasan ( )
Bahasa ( )
Memory ( )
Pengetahuan Umum ( )

KESIMPULAN PEMERIKSAAN :

PENUNJANG :

DIAGNOSA BANDING :

DIAGNOSA KLINIS :

TERAPI :

ANJURAN :