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RSUD PALEMBANG BARI RM.SRF.

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ANAMNESIS
Nama: ....................................... Umur L/P : ................................

Tanggal : Dokter Muda : .......................................

Dari : pasien sendiri / ayah / ibu / orang lain Dokter : ..............................................


RSUD PALEMBANG BARI RM.SRF.2

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PEMERIKSAAN FISIK
Nama : ....................................... Umur L/P : ................................

A. Status Praesens Status Internus


Kesadaran : ...................................... Jantung : .....................................................
Gizi : ...................................... Paru : .....................................................
Suhu Badan : ...................................... Hepar : .....................................................
Nadi : ...................................... Lien : .....................................................
Pernapasan : ...................................... Anggota Gerak : .....................................................
Tekanan Darah : ...................................... Genetalia : .....................................................
Berat Badan : ......................................
Tinggi Badan : ......................................

Status Psikis
Sikap : ...................................... Ekspresi Muka : .....................................................
Perhatian : ...................................... Kontak Psikis : .....................................................

B. Status Neurologis
1. Kepala
Bentuk : ...............................................
Ukuran : ...............................................
Simetris : ...............................................

2. Leher
Sikap : ........................................ Deformitas : ..............................................
Torticollis : ........................................ Tumor : ..............................................
Kaku kuduk : ........................................ Pembuluh darah : ..............................................
C. Syaraf-syaraf Otak
1. N. Olfaktorius Kanan Kiri
Penciuman : ................................................................ ...................................................................
Anosmia : ................................................................ ...................................................................
Hyposmia : ................................................................ ...................................................................
Parosmia : ................................................................ ...................................................................

2. N. Optikus
Visus : ................................................................ ...................................................................

Campus Visi
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PEMERIKSAAN FISIK
Nama : ....................................... Umur L/P : ................................
Kanan Kiri
- Anopsia : ................................................................ ...................................................................
- Hemianopsia : ................................................................ ...................................................................

Fundus oculi
- Papil edema : ................................................................ ...................................................................
- Papil atrofi : ................................................................ ...................................................................
- Perdarahan retina : ........................................................ ...................................................................

3. N. Oculomotorius, Trochlearis, dan Abducen


Kanan Kiri
Diplopia : ................................................................ ...................................................................
Celah mata : ................................................................ ...................................................................
Ptosis : ................................................................ ...................................................................
Sikap bola mata : ............................................................. ...................................................................
- Strabismus : ................................................................ ...................................................................
- Exopthalmus: ................................................................ ...................................................................
- Enopthalmus : ................................................................ ...................................................................
- Deviation conjuge : ....................................................... ...................................................................
Gerakan bola mata : ........................................................ ...................................................................
Pupil : ................................................................ ...................................................................
- Bentuk : ................................................................ ...................................................................
- Diameter : ................................................................ ...................................................................
- Iso/Anisokor : ................................................................ ...................................................................
- Midriasis/Miosis : ......................................................... ...................................................................
- Refleks Cahaya : ........................................................... ...................................................................
• Langsung : ................................................................ ...................................................................
• Konsensuil : ................................................................ ...................................................................
• Akomodasi : ................................................................ ...................................................................
- Argyl Robetson : ........................................................... ...................................................................

4. N. Trigeminus
Motorik Kanan Kiri
- Menggigit : ................................................................ ...................................................................
- Trismus : ................................................................ ...................................................................
- Refleks kornea : ............................................................ ...................................................................
Sensorik
- Dahi : ................................................................ ...................................................................
- Pipi : ................................................................ ...................................................................
- Dagu : ................................................................ ...................................................................
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PEMERIKSAAN FISIK
Nama : ....................................... Umur L/P : ................................

5. N. Facialis
MotorikKanan Kiri
- Mengerutkan dahi : ...................................................... ...................................................................
- Menutup mata : .............................................................. ...................................................................
- Menunjukkan gigi : ....................................................... ...................................................................
- Lipat nasolabialis : ........................................................ ...................................................................
- Bentuk muka
• Istirahat : .................................................................... ...................................................................
• Bicara/bersiul : ............................................................ ...................................................................

Sensorik
- 2/3 depan lidah : ........................................................ ...................................................................

Otonom
- Salivasi : ........................................................................ ...................................................................
- Lakrimasi : .................................................................... ...................................................................

Chovstek’s sign : ............................................................. ...................................................................

6. N. Cochlearis
Kanan Kiri
Suara bisikan : ................................................................ ...................................................................
Detik arloji : ................................................................ ...................................................................
Test Weber : ................................................................ ...................................................................
Test Rinne : ................................................................ ...................................................................

7. N. Vagus dan Glossopharingeous

Arcus pharynx : .............................................................. ...................................................................


Uvula : ................................................................ ...................................................................
Gg. Menelan : ................................................................ ...................................................................
Suara bicara : ................................................................ ...................................................................
Denyut jantung : .............................................................. ...................................................................
Refleks
- Muntah : ................................................................ ...................................................................
- Batuk : ................................................................ ...................................................................
- Oculocardiac : ............................................................... ...................................................................
- Sinus caroticus : ............................................................ ...................................................................

Sensorik
- 1/3 belakang lidah : ....................................................... ...................................................................
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PEMERIKSAAN FISIK
Nama : ....................................... Umur L/P : ................................

8. N. Acessorius
Kanan Kiri
- Mengangkat bahu : ........................................................ ...................................................................
- Memutar kepada : ......................................................... ...................................................................

9. N. Hypoglosus
Kanan Kiri
Menjulurkan lidah : ......................................................... ...................................................................
Fasikulasi : ................................................................ ...................................................................
Atrofi papil lidah : .......................................................... ...................................................................
Dysatria : ................................................................ ...................................................................

D. Columna Vertebralis
Kyphosis : ........................................................................................................................................
Scoliosis : ........................................................................................................................................
Lordosis : ........................................................................................................................................
Gibbus : ........................................................................................................................................
Deformitas : ........................................................................................................................................
Tumor : ........................................................................................................................................
Meningocele : ........................................................................................................................................
Hematoma : ........................................................................................................................................
Nyeri ketok : ........................................................................................................................................
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PEMERIKSAAN FISIK
Nama : ....................................... Umur L/P : ................................

E. Badan dan Anggota Gerak


Motorik

Lengan Kanan Kiri


- Gerakan : ................................................................ ...................................................................
- Kekuatan : ................................................................ ...................................................................
- Tonus : ................................................................ ...................................................................
- Refleks fisiologis
• Biceps : ................................................................ ...................................................................
• Triceps : ................................................................ ...................................................................
• Periost Radius : ........................................................... ...................................................................
• Periost Ulna : .............................................................. ...................................................................
- Refleks patologis
• Hoffman Tromner : .................................................... ...................................................................
- Trofik : .......................................................................... ...................................................................

Tungkai Kanan Kiri


- Gerakan : ................................................................ ...................................................................
- Kekuatan : ................................................................ ...................................................................
- Tonus : ................................................................ ...................................................................
- Klonus : ................................................................ ...................................................................
• Paha : ................................................................ ...................................................................
• Kaki : ................................................................ ...................................................................
- Refleks fisiologis
• KPR : ................................................................ ...................................................................
• APR : ................................................................ ...................................................................
- Refleks patologis
• Babinsky : ................................................................ ...................................................................
• Chaddock : ................................................................ ...................................................................
• Oppenheim : ................................................................ ...................................................................
• Gordon : ................................................................ ...................................................................
• Schaeffer : ................................................................ ...................................................................
• Rossolimo : ................................................................ ...................................................................
• Mendel Bechtereyev : ................................................ ...................................................................
- Refleks kulit perut
• Atas : ................................................................ ...................................................................
• Tengah : ................................................................ ...................................................................
• Bawah : ................................................................ ...................................................................
• Tropik : ................................................................ ...................................................................
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PEMERIKSAAN FISIK
Nama : ....................................... Umur L/P : ................................

Sensorik:

F. GAMBAR
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PEMERIKSAAN FISIK
Nama : ....................................... Umur L/P : ................................

G. Gejala Rangsang Meningeal


Kanan Kiri
- Kaku kuduk : ................................................................ ...................................................................
- Kernig : ................................................................ ...................................................................
- Lassergue : ................................................................ ...................................................................
- Brudzinsky
• Neck : ................................................................ ...................................................................
• Cheeck : ................................................................ ...................................................................
• Symphysis : ................................................................ ...................................................................
• Leg I : ................................................................ ...................................................................
• Leg II : ................................................................ ...................................................................

H. Gait dan Keseimbangan


Gait Keseimbangan
- Ataxia : ................................................................ - Romberg : .....................................
- Hemiplegic : ................................................................ - Dysmetri : .....................................
- Scissor : ................................................................ • Jari - jari : .....................................
- Propulsion : ................................................................ • Jari - hidung : .....................................
- Histeric : ................................................................ • Tumit - tumit : .....................................
- Limping : ................................................................ • Dysdiadochokinesis : ..........................
- Steppage : ................................................................ • Trunk ataxia : .....................................
- Astasia-abasia : .............................................................. • Limb ataxia : .....................................

I. Gerakan Abnormal
- Tremor : .......................................................................................................................................
- Chorea : .......................................................................................................................................
- Athetosis : .......................................................................................................................................
- Ballismus : .......................................................................................................................................
- Dystoni : .......................................................................................................................................
- Myoclonic : .......................................................................................................................................
J. Fungsi Vegetatif
- Miksi : .......................................................................................................................................
- Defekasi : .......................................................................................................................................
- Ereksi : .......................................................................................................................................
K. Fungsi Luhur
- Afasia motorik : ................................................................................................................................
- Afasia sensorik : ................................................................................................................................
- Afasia nominal : ................................................................................................................................
- Apraksia : ................................................................................................................................
- Agrafia : ................................................................................................................................
- alexia : ................................................................................................................................
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PEMERIKSAAN Ruang : ...................................... No. Rek.Med : ..........................


PENUNJANG
Nama : ....................................... Umur L/P : ................................
Laboratorium
Darah : Urine : Faeces :

Liquor Cerebro Spinal


- Warna : ................................................................ - Protein : .....................................
- Kejernihan : ................................................................ - Glukose : .....................................
- Tekanan : ................................................................ - Queckensted : .....................................
- Jumlah Sel : ................................................................ - Kultur : .....................................
- Nonne : ................................................................ - Pandy : .....................................

Pemeriksaan Khusus
- Ro. Cranium : ..............................................................................................................................
- Ro. Thorax : ..............................................................................................................................
- Coll. Vertebralis : ..............................................................................................................................
- ElectroEncephaloGraphy : ........................................................................................................................
- Arteriography : ..............................................................................................................................
- Electrocardiography : ..............................................................................................................................
- Pneumigraphy : ..............................................................................................................................
- Lain-lain : ..............................................................................................................................

DIAGNOSA KLINIK : ....................................................................................................................


....................................................................................................................
DIAGNOSA TOPIK : ....................................................................................................................
....................................................................................................................
DIAGNOSA ETIOLOGI : ....................................................................................................................
....................................................................................................................
....................................................................................................................
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RINGKASAN
Nama : ....................................... Umur L/P : ................................
Anamnesis :

Pemeriksaan :

Diagnosa Klinik : ....................................................................................................................


Diagnosa Topik : ....................................................................................................................
Diagnosa Etiologi : ....................................................................................................................
Pengobatan :

Pembuat catatan medik,


Dokter Muda, Dokter Penanggung Jawab,

................................................. ............................................................
RSUD PALEMBANG BARI RM.SRF.11
Lembar Follow-Up Dokter Muda
Nama Pasien : ............................... Ruang Rawat : .................................. No. MedRec: ............
Umur : ................. L/P Dokter Muda : .................................
Tanggal / Pkl Perjalanan Penyakit Instruksi / Rencana Therapy