Pomr Ikfr Stroke
Pomr Ikfr Stroke
Case : Stroke
DATA BASE
I. IDENTITY
Name / Sex / Age
Married / Not Married
Occupation / Education
Religion
Address
Health Insurance
Other complaints
Gejala penyerta : tidak sadar / muntah / kejang
ADLs :
Barthel index
Basic – include sexual history
Advance – social interaction, A working ability to
Review of systems (Quick 1) : Head to toe
V. FAMILY HISTORY
Eksplorasi faktor risiko pada keluarga, missal : riwayat stroke pada keluarga,
riwayat HT dll
Sensoris :
Eksteroseptif : nyeri, raba, suhu
Proprioseptif :
Joint position
Vibration
Two point tactile discrimination, grafestesia, stereognosia
Extinction phenomenon
Hemineglect : clock drawing
Fungsi luhur : MMSE, Lotca
Keseimbangan : static, dinamik, duduk, berdiri, Romberg, tandem
walking
Gait (bila px mampu berjalan)
Kemampuan berbahasa : fluency, comprehension, repetition, naming
Memori : jangka pendek dan panjang
Pemeriksaan apraxia (kemampuan melakukan gerakan berurutan dan
bertujuan)
VIII. DIAGNOSIS
I. FUNCTIONAL DIAGNOSIS
Impairment
Disability
Handicap
II. GOALS
Goals (Short/Immediate, Intermediate, Long/Ultimate)
Acute : limits neurologic damage, monitor & prevent complications
Sub-acute : Independent ambulation with aids, ADLs with some help, involve
both extremity (hand) , Can safely swallow food/water, Communicate
Intermediate goal : Achieve max. level of independent, minimize disability, re-
integrate back into home, family, optimize neurological recovery (short –
intermediate)
Long term goal : Return to optimally function as before, Prevent recurrent
stroke, Back to work with some adjustments
III.PLANNING
Diagnosis
Therapy
Monitoring
Education
IX. PROGNOSIS
Ad vitam
Ad sanam
Ad functionam
Compiled by WA