3

LAPORAN KASUS

2.1 Identitas Pasien

Nama :
Umur :
Jenis kelamin :
TTL :
Agama :
Suku :
Alamat :
Pendidikan :
Pekerjaan :
Status Perkawinan :
Masuk RS : 20

2.2 Anamnesis
1. Keluhan utama :
2. Riwayat penyakit sekarang :
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3. Riwayat penyakit dahulu

a. Riwayat Keluhan Serupa :

b. Riwayat Kencing Manis :

c. Riwayat Darah Tinggi :
d. Riwayat Penyakit Jantung :
e. Riwayat Sakit Ginjal :
f. Riwayat Asma :
g. Riwayat Asam Urat :
h. Riwayat Kolesterol :
i. Riwayat Trauma / Jatuh :
4. Riwayat penyakit keluarga
a. Riwayat Penyakit Serupa :
b. Riwayat Darah Tinggi :
c. Riwayat Kencing Manis :
d. Riwayat Penyakit Jantung :
e. Riwayat Penyakit Ginjal :
5. Riwayat kebiasaan :

6. Riwayat sosial ekonomi :

7. Riwayat gizi :
8. Riwayat pengobatan :
9. Riwayat Alergi :
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2.3 Pemeriksaan Fisik

2.3.1 Status Generalisata
1. Keadaan Umum :
2. GCS :
3. Tanda Vital
a. Tensi : / mmHg
b. Nadi : x/menit
c. RR : x/menit
0
d. Suhu : C
e. BB : Kg
f. TB : cm
g. BMI :

4. Mata
Konjungtiva anemis (-/-), sklera ikterik (-/-), reflek cahaya (+/+),
katarak (-/-) , bengkak (-/-)
5. Leher
JVP tidak meningkat, trakea ditengah, pembesaran kelenjar tiroid (-),
pembesaran kelenjar limfe (-), lesi pada kulit (-)
6. Thoraks
Simetris, bentuk , retraksi subkostal (-),
Sonor/Sonor, Rhonki -/-, Wheezing -/-
7. Abdomen
Peristaltik normal, timpani, supel, nyeri tekan epigastrium (-)
hepar dan lien tidak teraba
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8. Sistem muskulus skeletal

Part of Body Joint Movement Muscles Strength

Movement Range of Motion Muscles MMT

Neck Flexion Full Flexor 5

Extension Full Extensor 5

Lateral flexion Full / full Lateral Flexor 5/5

Rotation Full / full Rotator 5/5

Trunk Flexion Full Flexor good

balance
Extension Full Extensor

Lateral flexion Full Lateral Flexor

Rotation Full Rotator

Shoulder Flexion Full / full Flexor 5/5

Extension Full / full Extensor 5/5

Abduction Full / full Abductor 5/5

Adduction Full / full Adductor 5/5

Int. Rotation Full / full Int. Rotator 5/5

Ext.Rotation Full / full Ext.Rotator 5/5

Elbow Flexion Full / full Flexor 5/5

Extension Full / full Extensor 5/5

Pronation Full / full Pronator 5/5

Supination Full / full Supinator 5/5

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Wrist Flexion Full / full Flexor 5/5

Extension Full / full Extensor 5/5

Radial Dev. Full / full Radial Deviator 5/5

Ulnar Dev. Full / full Ulnar Deviator 5/5

Fingers Flexion Full / full Flexor 5/5

Extension Full / full Extensor 5/5

Abduction Full / full Abductor 5/5

Adduction Full / full Adductor 5/5

Hip Flexion Full / full Flexor 5/5

Extension Full / full Extensor 5/5

Abduction Full / full Abductor 5/5

Adduction Full / full Adductor 5/5

Int. Rotation Full / full Int. Rotator 5/5

Ext.Rotation Full / full Ext.Rotator 5/5

Knee Flexion- Ekstension Full / full Flexion- Ekstension 5/5

Ankle Dorsoflexion Full / full Dorsoflexor 5/5

Plantarflexion Full / full Plantarflexor 5/5

Eversion Full / full Evertor 5/5

Inversion Full / full Invertor 5/5

Toes Flexion Full / full Flexor 5/5

Extension Full / full Extensor 5/5

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2.4.2 Status Lokalis : Regio Genu Dextra dan Sinistra

Look : Deformitas (-/-) valgus, edema (-/-), hiperemi (-/-), varus
(-/-)
Feel : Krepitasi (-/-), edema (-/-)
Movement : Nyeri gerak aktif (-), nyeri gerak pasif (-)
terbatas pada gerakan fleksi lutut

ROM : D
S
Skala nyeri sedang yaitu

2.4 Barthel Index

Activity Score
Feeding 10
Bathing 5
Grooming 5
Dressing 10
Bowels 10
Bladder 10
Toilet use 10
Transfers 15
Mobility 15
Stairs 10
TOTAL 100
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2.5 Diagnosa kerja

2.6 Diagnosa fungsional

1. Impairment :

2. Disabilitas :

3. Handicap :


2.7 Problem List

1.
2.
3.
4.
5.
2.8 Planning Diagnosa
1.
2.
3.
4.
5.
2.9 Planning Monitoring
1.
2.
3.
4.
5.
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2.10 Planning Terapi

Rehabilitasi:

Edukasi:

2.11 Hasil Laboratorium