STATUS RAWAT JALAN

POLIKLINIK SARAF
NO. REKAM MEDIS : ALLERGI OBAT : ___________________________

NAMA PASIEN : _______________________________ __________________________________________

ANAMNESA : LAKI-LAKI PEREMPUAN
JENIS KELAMIN : KELUHAN UTAMA :
USIA : ___ TAHUN ___________________________________________
AGAMA : _______________________________ ___________________________________________
PEKERJAAN : SWASTA WIRASWASTA KELUHAN TAMBAHAN :
PEG. NEGERI LAIN-LAIN………………………….. ___________________________________________
PENDIDIKAN : SMU/SMK D3 S1 ___________________________________________
ALAMAT : RIWAYAT PENYAKIT SEKARANG :
___________________________________________
PEMERIKSAAN FISIK ___________________________________________
KEADAAN UMUM : RIWAYAT PENYAKIT DAHULU
KESADARAN : ___________________________________________
TANDA VITAL : N : __ RR : __ SUHU : __°C BB : __kg

NEUROLOGIS Pemeriksaan Motorik

Pemeriksaan Pupil Kekuatan : Kanan : ____________ / _______________

Bentuk Pupil :
Kiri : ___________ / _______________
Reflek cahaya : langsung ___________ Tidak langsung __________
Tonus : Kanan : ___________ / ________________
Pemeriksaan Nn.Craniales
Kiri : __________ / _________________:
NI : _______________________________________________________
Trofi : Kanan : _________ / _________________
NII : _______________________________________________________
Kiri : __________ / ________________
NIII, IV, VI : _______________________________________________________
Pemeriksaan Reflek
NV : _______________________________________________________

NVII : ______________________________________________________ Meningen : ___________________________________

NVIII : ______________________________________________________ _____________________________________________

NIX, X : ______________________________________________________ Fisiologis :____________________________________

NXI : ______________________________________________________
Patologis : ____________________________________
NXII : ______________________________________________________
______________________________________________

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 Pemeriksaan Sensorik : ____________________________________ Pemeriksaan Otonom ;

________________________________________________________ Koordinasi ; Nistagmus : ___________________

________________________________________________________ Tes tunjuk : ___________________

_______________________________________________________ Tes Romberg : ___________________

PEMERIKSAAN PENUNJANG : __________________________________________________________________________________________

_____________________________________________________________________________________________________ ________________________

DIAGNOSIS KERJA :__________________________________________________________________________________

________________________________________________________________________________________________________

PENATALAKSANAAN :

MEDIKAMENTOSA : _________________________________________________________________________________

NON MEDIKAMENTOSA :__________________________________________________________________________________

KOMPLIKASI :_____________________________________________________________________________________

PROGNOSIS : ______________________________________________ ________________________________________

________________________________________________________________________________________________________

Kota Tangerang Selatan, …. - … 20….

Dokter yang memeriksa

( ________________________ )

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