FK UNSRI PALEMBANG RM.

R 1
BAGIAN REHABILITASI MEDIK

ANAMNESIS Ruang :……………………….. No.Rek.Med :……………………………

Nama :……………………….. Umur / Jenis :………………………L / P

Alamat :……………………………………………. Agama :……………………
Pekerjaan : …………………………………………… Status perkawinan :…………………….
Tanggal pemeriksaa :…………………………………….. Dokter muda :……………………

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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4. RIWAYAT PENYAKIT PADA KELUARGA

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5. RIWAYAT PEKERJAAN
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6. RIWAYAT SOSIAL EKONOMI
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FK UNSRI PALEMBANG RM.R 2
BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK Ruang : No.Rek.Med :

Nama : 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 : / mmHg
Nadi : x / menit
Pernafasan : x / menit
Suhu : C
Kulit :
Status Psikis
Sikap : Orientasi :........................................
Ekspresi wajah : Perhatian :........................................
FK UNSRI PALEMBANG RM.R 3
BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK Ruang : No.Rek.Med :

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 4
BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK Ruang : No.Rek.Med :

Nama : Umur : L / P

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 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 : ……………………………………………………………………………
FK UNSRI PALEMBANG RM.R 5
BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK Ruang : No.Rek.Med :

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 :…./……. Test: O’Connell :……./………
- FNST :…../…….Test Patrick :…. /…….Test Kontra Patrick :……/ ………
- Test Gaenslen :…../…….Test Thomas:…. /……. Test Ober’s :……/………
- Nachalas knee flexion test :……../…….. Mc.Bride sitting test :……./……..
- Yeoman’s hyprextension :……../…….. Mc.Bridge toe to mouth sitting test ;……./……..
- Test Schober :………………………………………………………………………………

H. Anggota Gerak Atas

Inspeksi kanan kiri
- Deformitas : ………………………. ……………………………
- Edema : ……………………… ……………………………
- Tremor : ……………………… ……………………………
 FK UNSRI PALEMBANG RM.R 6
BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK / Ruang : No.Rek.Med :

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 Fisiologis
Refleks tendon biseps ............................... .......................................
Refleks tendon triseps .............................. ......................................
Refleks Patologis
Hoffman ............................... .......................................
Tromner .............................. ........................................

Sensorik
Protopatik :.....................................................................................................................
Proprioseptik :....................................................................................................................
Vegetatif :.......................................................................................................

Penilaian fungsi tangan kanan kiri

Anatomical ................. .........................
Grips ................. ……………….
Spread …………. ……………….
Palmar abduct …………… …………………
Pinch …………… ………………...
FK UNSRI PALEMBANG RM.R 7
BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK / LGS Ruang : No.Rek.Med :

Nama : Umur : L / P

Luas gerak sendi Aktif Aktif Pasif Pasif

Dexra sinistra Dexra 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 : ………………… …………………

PEMERIKSAAN FISIK Ruang : No.Rek.Med :

FK UNSRI PALEMBANG RM.R 8
BAGIAN REHABILITASI MEDIK

Nama : Umur : L / P

I. Anggota Gerak Bawah

Inspeksi kanan kiri
- Deformitas : ……………….. ………………
- Edema : ………………. .......................
- Tremor : ......................... .......................
Palpasi
- Nyeri tekan ( lokasi ) : ........................... ..........................
- Diskrepansi : ........................... ..........................

Neurologi

Motorik kanan kiri

Gerakan ........... ...........
Kekuatan
Fleksi paha ............ ..............
Ekstensi paha ............ ..............
Ekstensi lutut ............ ...............
Fleksi lutut ............. ...............
Dorsofleksi pergelangan kaki ............. ................
Dorsofleksi ibu jari kaki .............. ................
Plantar fleksi pergelangan kaki .............. ...............
Tonus ............... ................
Tropi ................ ...................
Refleks Fisiologis
Refleks tendo patella ................ …………...
Refleks tendo achilles ………… …………..
Refleks patologi
Babinsky …………… ……………
Chaddock …………… ……………
FK UNSRI PALEMBANG RM.R 9
BAGIAN REHABILITASI MEDIK

PEMERIKSAAN FISIK / LGS Ruang : No.Rek.Med :

Nama : Umur : L / P

Sensorik kanan kiri

- Protopatik : ……………. ……………….
- Proprioseptik : ……………. ………………

Vegetatif : ……………. ………………

Luas gerak sendi

Luas gerak Aktif Aktif Pasif Pasif
Sendi Dextra Sinistra Dextra Sinistra

Fleksi paha ……… ………. ………… ………..

Ekstensi paha ……… ………. ………… ………..
Endorotasi paha ……… ………. ………… ………..
Adduksi paha ……… ………. ………… ………..
Abduksi paha ……… ………. ………… ………..
Fleksi lutut ……… ………. ………… ………..
Ekstensi lutut ……… ………. ………… ………..
Dorsofleksi pergelangan kaki ……… ………. ………… ……….
Plantar fleksi pergelangan kaki ……… ………. ………… ……….
Inversi kaki ……… ………. ………… ……….
Eversi kaki ……… ………. ………… ……….

Test Provokasi sendi lutut kanan kiri

Stres test ................ ...................
Drawer’s test ................ ....................
Test Tunel pada sendi lutut ................. ....................
Test Homan ................. ....................
Test lain – lain ................... ......................

PEMERIKSAAN FISIK Ruang : No.Rek.Med :

Nama : Umur : L / P
FK UNSRI PALEMBANG RM.R 10
BAGIAN REHABILITASI MEDIK

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 :
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B. Laboratorium :
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C. Lain –lain CT – Scan / MRI :
RESUME Ruang : No.Rek.Med :
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Nama : Umur : L / P
FK UNSRI PALEMBANG RM.R 11
BAGIAN REHABILITASI MEDIK

RESUME Ruang : No.Rek.Med :

Nama : Umur : L / P

V RESUME
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EVALUASI / DIAGNOSIS Ruang : No.Rek.Med :

FK UNSRI PALEMBANG RM.R 12
BAGIAN REHABILITASI MEDIK

Nama : Umur : L / P

VI. EVALUASI

NO Level ICF Kondisi saat ini Sasaran

1 Struktur dan fungsi tubuh …………………………….. ……………………………..
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2 Aktivitas …………………………….. ……………………………..
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3 Partisipasi …………………………….. ……………………………..

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Catatn : ICF International Clasification of Function ( WHO 2002 )

DIAGNOSIS KLINIS
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PROGRAM REHABILITASI Ruang : No.Rek.Med :

FK UNSRI PALEMBANG RM.R 13
BAGIAN REHABILITASI MEDIK

Nama : Umur : L / P

VII. PROGRAM REHABILITASI MEDIK

Fisioterapi

Terapi panas :.............................................................................................................

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Terapi dingin :..............................................................................................................
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Stimulasi listrik :..............................................................................................................
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Terapi latihan : .............................................................................................................
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Okupasi terapi

ROM excercise : .......................................................................................

ADL Excercise : .......................................................................................

Ortotik prostetik
Ortotic :................................................................................................
Prostetic : ...............................................................................................
Alat bantu ambulasi :................................................................................................

Terapi wicara
Afasia : ................................................................................................
Dysartria :.................................................................................................
Dysfagia :.................................................................................................

Social medik :.................................................................................................

Edukasi :..................................................................................................

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TERAPI Ruang : No.Rek.Med :

FK UNSRI PALEMBANG RM.R 14
BAGIAN REHABILITASI MEDIK

PROGNOSA / FOLLOW UP Nama : Umur : L / P

VIII. TERAPI MEDIKAMENTOSA

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PEMERIKSAAN FISIK Ruang : No.Rek.Med :
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Nama : Umur : L / P
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IX . PROGNOSA
Mmmm - Medik :……………………………………………………………………………

- Fungsional :…………………………………………………………………………….

X . FOLLOW UP

Tanggal :…………………………………………………………………………….

Keluhan : …………………………………………………………………………….

Pemeriksaan Umum : …………………………………………………………………………….

Keadaan khusus : …………………………………………………………………………….

Fungsional : Barthel Index :

FIM Index :

Katz index :