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

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

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

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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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Kanan
- Anopsia : ................................................................ ...................................................................
- Hemianopsia: ................................................................ ...................................................................
Fundus oculi
- Papil edema : ................................................................
- Papil atrofi : ................................................................
- Perdarahan retina : ........................................................
3. N. Oculomotorius, Trochlearis, dan Abducen
Kanan
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
- Menggigit : ................................................................
- Trismus : ................................................................
- Refleks kornea : ............................................................
Sensorik
- Dahi : ................................................................
- Pipi : ................................................................
- Dagu : ................................................................
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Kiri
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PEMERIKSAAN FISIK
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5. N. Facialis
Motorik Kanan
- Mengerutkan dahi : ......................................................
- Menutup mata : ..............................................................
- Menunjukkan gigi : .......................................................
- Lipat nasolabialis : ........................................................
- Bentuk muka
• Istirahat : ....................................................................
• Bicara/bersiul : ............................................................
Kiri
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Sensorik
- 2/3 depan lidah : ........................................................ ...................................................................

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

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

6. N. Cochlearis
Kanan
Suara bisikan : ................................................................
Detik arloji : ................................................................
Test Weber : ................................................................
Test Rinne : ................................................................
Kiri
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7. N. Vagus dan Glossopharingeous

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

Uvula : ................................................................
Gg. Menelan : ................................................................
Suara bicara : ................................................................
Denyut jantung : ..............................................................
Refleks
- Muntah : ................................................................
- Batuk : ................................................................
- Oculocardiac : ...............................................................
- Sinus caroticus : ............................................................
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Sensorik
- 1/3 belakang lidah : ....................................................... ...................................................................
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PEMERIKSAAN FISIK
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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
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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 : ..........................................................................
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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
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Sensorik:

F. G A M B A R
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PEMERIKSAAN FISIK
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G. Gejala Rangsang Meningeal

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

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

Pemeriksaan :

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

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

Pembuat catatan medik, Dokter Penanggung Jawab,

Dokter Muda,

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Lembar Follow-Up Dokter Muda
Nama Pasien : ............................... Ruang Rawat : .................................. No. MedRec: ............
Umur : ................. L/P Dokter Muda : .................................
Tanggal / Pkl Perjalanan Penyakit Instruksi / Rencana Therapy
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Lembar Diskusi
Nama Pasien : ............................... Ruang Rawat : .................................. No. MedRec: ............
Umur : ................. L/P Dokter Muda : .................................
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