FK UNSRI PALEMBANG
RM.R
BAGIAN REHABILITASI MEDIK
ANAMNESIS
Ruang :………………………..
No.Rek.Med :……………………………
Alamat
Nama :……………………….. :…………………………………………….
Umur / Jenis :………………………L / P Agama :……………………
Pekerjaan
: ……………………………………………
Status perkawinan :…………………….
Tanggal pemeriksaa :……………………………………..
Dokter muda
:……………………
1. ANAMNESIS 2. KELUHAN UTAMA …………………………………………………………………………………………………. 3. RIWAYAT PENYAKIT SEKARANG …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. 4. RIWAYAT PENYAKIT / OPERASI DAHULU …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. 5. RIWAYAT PENYAKIT PADA KELUARGA …………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………. ………………………………………………………………………………………………… 6. RIWAYAT PEKERJAAN ……………………………………………………………………………………………… ………………………………………………………………………………………………… 7. RIWAYAT SOSIAL EKONOMI …………………………………………………………………………………………………. …………………………………………………………………………………………………
1
FK UNSRI PALEMBANG
RM.R
BAGIAN REHABILITASI MEDIK PEMERIKSAAN FISIK
Ruang : Nama :
No.Rek.Med : Umur :
L / P
II. PEMERIKSAAN FISIK A. Pemeriksaan Umum Keadaan Umum
: baik / sedang / buruk
Kesadaran
:G C S :
Tinggi Badan / Berat Badan :
cm /
kg
BMI :
Cara berjalan / Gait Antalgik gait
:.............................................................................................
Hemiparese gait
:……………………………………………………………
Steppage gait
: .............................................................................................
Parkinson gait
: .............................................................................................
Tredelenberg gait : ............................................................................................. Waddle gait
: .............................................................................................
Lain – lain
: .............................................................................................
Bahasa / bicara Komunikasi verbal
: .............................................................................................
Komunikasi nonverbal: ............................................................................................. Tanda vital Tekanan darah
:
/
Nadi
:
x / menit
Pernafasan
:
x / menit
Suhu
:
Kulit
mmHg
C
:
Status Psikis Sikap
:
Orientasi
:........................................
Ekspresi wajah
:
Perhatian :........................................
2
FK UNSRI PALEMBANG
RM.R
BAGIAN REHABILITASI MEDIK PEMERIKSAAN FISIK
Ruang : Nama :
No.Rek.Med : Umur :
L / P
B. Saraf – saraf otak Nervus
kanan
kiri
I.
N.Olfaktorius
……………...
.................
II.
N.Opticus
.......................
.................
III.
N.Occulomotorius
.......................
..................
IV.
N.Trochlearis
.......................
.................
V.
N.Trigeminus
.......................
.................
VI.
N.Abducens
.......................
...................
VII.
N.Fascialis
......................
...................
VIII.
N.Vestibularis
......................
...................
IX.
N.Glossopharyngeus
......................
....................
X.
N.Vagus
.......................
....................
XI.
N.accesorius
.......................
....................
XII.
N.Hypoglosus
........................
....................
C. Kepala Bentuk
: ............................................................................................................
Ukuran
: ............................................................................................................
Posisi
:............................................................................................................. - Mata
:.............................................................................................................
- Hidung
:.............................................................................................................
- Telinga
:............................................................................................................
- Mulut
: ............................................................................................................
- Wajah
: simetris / asimetris
gerakan abnormal : ………………
3
FK UNSRI PALEMBANG
RM.R
4
BAGIAN REHABILITASI MEDIK PEMERIKSAAN FISIK
Ruang : Nama :
D. Leher Inspeksi
No.Rek.Med : Umur :
L / P
:…………………………………………………………………………………
Palpasi
: ………………………………………………………………………………..
Luas Gerak Sendi Ante / retrofleksi
( n 65 / 50 ) : ………/………….
Laterofleksi ( D/S )
( n 40 / 40 ) :………/………….
Rotasi
( n 45 / 45 ) : ………/………..
( D/S )
Test provokasi Lhermitte test / Spurling
:……………… Test Valsalva :……………………….
Distraksi test
:……………… Test Nafziger :……………………….
E. Thorak Bentuk
:……………………………………………………….
Pemeriksaan Ekspansi Thoraks : Ekspirasi maksimum .......Cm Inspirasi Maksimum ..........cm Paru- paru -
Inspeksi
: …………………………………………………………………………..
-
Palpasi
:…………………………………………………………………………..
-
Perkusi
: ………………………………………………………………………….
-
Auskultasi
: ……………………………………………………………………………..
Jantung -
Inspeksi
: ……………………………………………………………………………..
-
Palpasi
: …………………………………………………………………………….
-
Perkusi
: ……………………………………………………………………………..
-
Auskultasi
: ……………………………………………………………………………..
F. Abdomen -
Inspeksi
: …………………………………………………………………………….
-
Palpasi
: …………………………………………………………………………….
-
Perkusi
: …………………………………………………………………………….
-
Auskultasi
: ……………………………………………………………………………
FK UNSRI PALEMBANG
RM.R
BAGIAN REHABILITASI MEDIK PEMERIKSAAN FISIK
Ruang : Nama :
No.Rek.Med : Umur :
L / P
G. Trunkus Inspeksi : Simetris
:………………………………………………………………………….
-
Deformitas
:…………………………………………………………………………..
-
Lordosis
:…………………………………………………………………………..
-
Scoliosis
:………………………………………………………………………….
-
Gibbus
:………………………………………………………………………….
-
Hairy spot
:…………………………………………………………………………..
-
Pelvic Tilt
:…………………………………………………………………………
Palpasi : -
Spasme otot-otot para vertebrae
:…………………………………………………………
-
Nyeri tekan
:…………………………………………………………
( lokasi )
Luas gerak sendi lumbosakral -
Ante /retro fleksi (95/35)
:……………./……………..
-
Laterofleksi (D/S) (40/40)
:……………/……………...
-
Rotasi (D/S) (35/35)
:……………./…………….
Test provokasi -
Valsava test
:…………Tes Laseque :…./…….Test : Baragard dan Sicard :……./……….
-
Niffziger test
: …………Test SLR
-
FNST
:…../…….Test Patrick :…. /…….Test Kontra Patrick
:……/ ………
-
Test Gaenslen
:…../…….Test Thomas:…. /……. Test Ober’s
:……/………
-
Nachalas knee flexion test :……../…….. Mc.Bride sitting test
:……./……..
-
Yeoman’s hyprextension :……../…….. Mc.Bridge toe to mouth sitting test
;……./……..
-
Test Schober
:…./……. Test: O’Connell
:……./………
:………………………………………………………………………………
H. Anggota Gerak Atas Inspeksi
kanan
kiri
-
Deformitas
:
……………………….
……………………………
-
Edema
:
………………………
……………………………
-
Tremor
:
………………………
……………………………
5
FK UNSRI PALEMBANG
RM.R
BAGIAN REHABILITASI MEDIK PEMERIKSAAN FISIK / NEUROLOGI
Ruang : Nama :
No.Rek.Med : Umur :
L / P
Neurologi Motorik
Dextra
Sinistra
Gerakan
. .............................
........................................
Kekuatan
..............................
........................................
..............................
........................................
Abduksi lengan Fleksi siku
...............................
........................................
Ekstensi siku
...............................
........................................
Ekstensi Wrist
...............................
.........................................
Fleksi jari- jari tangan
...............................
........................................
Abduksi jari tangan
...............................
........................................
Tonus
...............................
.........................................
Tropi
...............................
........................................
Refleks tendon biseps
...............................
.......................................
Refleks tendon triseps
..............................
......................................
Hoffman
...............................
.......................................
Tromner
..............................
........................................
Refleks Fisiologis
Refleks Patologis
Sensorik Protopatik
:.....................................................................................................................
Proprioseptik
:....................................................................................................................
Vegetatif Penilaian fungsi tangan
:....................................................................................................... kanan
kiri
Anatomical
.................
.........................
Grips
.................
……………….
Spread
………….
……………….
Palmar abduct
……………
…………………
Pinch
……………
………………...
6
FK UNSRI PALEMBANG
RM.R
BAGIAN REHABILITASI MEDIK PEMERIKSAAN FISIK / LGS
Luas gerak sendi
Ruang : Nama :
No.Rek.Med : Umur :
Aktif Dexra
Aktif sinistra
Pasif Dexra
L / P Pasif Sinistra
Abduksi bahu
…………
.............
..................
................
Adduksi bahu
…………
………..
.................
................
Fleksi bahu
..............
...............
..................
................
Extensi bahu
...............
................
.................
................
Endorotasi bahu (f0)
................
................
.................
..................
Eksorotasi bahu (f0)
.................
.................
..................
...................
Endoratasi bahu (f90)
.................
.................
..................
..................
Eksorotasi bahu (f90)
..................
.................
...................
...................
Fleksi siku
.................
................
...................
...................
Ekstensi siku
..................
..................
..................
...................
Ekstensi pergelangan tangan
..................
..................
..................
....................
Fleksi pergelangan tangan
...................
..................
..................
....................
Supinasi
....................
…………..
…………..
…………….
Pronasi
……………
…………..
…………..
Test Provokasi
kanan
…………….
kiri
- Yergason test
:
…………………
………………….
- Apley scratch test
:
…………………
…………………
- Moseley test
:
…………………
………………….
- Adson manuver
:
…………………
…………………
- Tinel test
:
…………………
…………………
- Phalen test
:
…………………
………………….
- Prayer test
:
………………..
…………………
- Finkelstein
:
………………..
………………..
- Promet test
:
…………………
…………………
PEMERIKSAAN FISIK
Ruang :
No.Rek.Med :
7
FK UNSRI PALEMBANG
RM.R
8
BAGIAN REHABILITASI MEDIK Nama :
Umur
:
L / P
I. Anggota Gerak Bawah Inspeksi
kanan
kiri
-
Deformitas
:
………………..
………………
-
Edema
:
……………….
.......................
-
Tremor
:
.........................
.......................
Palpasi -
Nyeri tekan ( lokasi ) :
...........................
..........................
-
Diskrepansi
...........................
..........................
:
Neurologi Motorik
kanan
kiri
...........
...........
Fleksi paha
............
..............
Ekstensi paha
............
..............
Ekstensi lutut
............
...............
Fleksi lutut
.............
...............
Dorsofleksi pergelangan kaki
.............
................
Dorsofleksi ibu jari kaki
..............
................
Plantar fleksi pergelangan kaki
..............
...............
Tonus
...............
................
Tropi
................
...................
Refleks tendo patella
................
…………...
Refleks tendo achilles
…………
…………..
Babinsky
……………
……………
Chaddock
……………
……………
Gerakan Kekuatan
Refleks Fisiologis
Refleks patologi
FK UNSRI PALEMBANG
RM.R
BAGIAN REHABILITASI MEDIK PEMERIKSAAN FISIK / LGS
Ruang : Nama :
Sensorik
No.Rek.Med : Umur : kanan
L / P
kiri
- Protopatik
:
…………….
……………….
- Proprioseptik
:
…………….
………………
:
…………….
………………
Vegetatif Luas gerak sendi Luas gerak Sendi
Aktif Dextra
Aktif Sinistra
Pasif Dextra
Pasif Sinistra
Fleksi paha
………
……….
…………
………..
Ekstensi paha
………
……….
…………
………..
Endorotasi
………
……….
…………
………..
Adduksi paha
………
……….
…………
………..
Abduksi paha
………
……….
…………
………..
Fleksi lutut
………
……….
…………
………..
Ekstensi lutut
………
……….
…………
………..
Dorsofleksi pergelangan kaki
………
……….
…………
……….
Plantar fleksi pergelangan kaki
………
……….
…………
……….
Inversi kaki
………
……….
…………
……….
Eversi kaki
………
……….
…………
……….
paha
Test Provokasi sendi lutut
kanan
kiri
Stres test
................
...................
Drawer’s test
................
....................
Test Tunel pada sendi lutut
.................
....................
Test Homan
.................
....................
Test lain – lain
...................
......................
PEMERIKSAAN FISIK
Ruang : Nama :
No.Rek.Med : Umur :
L / P
9
FK UNSRI PALEMBANG
RM.R
10
BAGIAN REHABILITASI MEDIK
III. Pemeriksaan- pemeriksaan lainnya Pemeriksaan refleks –refleks primitive pada anak –anak dengan gangguan SSP Righting reaction
:…………………………………………………
Reaksi keseimbangan
:…………………………………………………
Pemeriksaan lainnya
:…………………………………………………
Bowel test / Bladder test -
Sensorik peri anal
:………………………….
-
Motorik sphincter ani eksternus
:………………………….
-
BCR
:………………………….
( Bulbocavernosis Refleks
Fungsi luhur -
Afasia
:………………………………………………….
-
Apraksia
:………………………………………………….
-
Agrafia
:…………………………………………………
-
Alexia
:………………………………………………….
IV. PEMERIKSAAN PENUNJANG A.
Radiologis
:
…………………………………………………………………………….. ……………………………………………………………………………... ……………………………………………………………………………... ……………………………………………………………………………… B.
Laboratorium : ………………………………………………………………………………… ………………………………………………………………………………….
C. RESUME
Lain –lain
CT – Scan / MRI :
Ruang : No.Rek.Med : ………………………………………………………………………………….. Nama : Umur : L / P
FK UNSRI PALEMBANG
RM.R
11
BAGIAN REHABILITASI MEDIK RESUME
Ruang : Nama :
No.Rek.Med : Umur :
L / P
V RESUME ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. EVALUASI / DIAGNOSIS
Ruang :
No.Rek.Med :
FK UNSRI PALEMBANG
RM.R
12
BAGIAN REHABILITASI MEDIK Nama :
Umur
:
L / P
VI. EVALUASI NO 1
Level ICF Struktur dan fungsi tubuh
2
Aktivitas
3
Partisipasi
Catatn : ICF
Kondisi saat ini …………………………….. ……………………………… ……………………………… ……………………………… ……………………………… ……………………………… ………………………………. ……………………………… …………………………….. …………………………….. …………………………….. …………………………….. …………………………….. ……………………………… ……………………………… ……………………………… ……………………………… ……………………………… ………………………………. ……………………………… ………………………………
Sasaran …………………………….. ……………………………… ……………………………… ……………………………… ……………………………… ……………………………… ………………………………. ……………………………… …………………………….. …………………………….. …………………………….. …………………………….. ……………………………… ……………………………… ……………………………… ……………………………… ……………………………… ………………………………. ……………………………… …………………………….. ……………………………
…………………………….. …………………………….. ……………………………… ……………………………… ……………………………… ……………………………… ……………………………… ………………………………. ………………………………
…………………………….. …………………………….. ……………………………… ……………………………… ……………………………… ……………………………… ……………………………… ………………………………. ……………………………
International Clasification of Function ( WHO 2002 )
DIAGNOSIS KLINIS ..................................................................................................................................................................... ...................................................................................................................................................................
PROGRAM REHABILITASI
Ruang :
No.Rek.Med :
FK UNSRI PALEMBANG
RM.R
13
BAGIAN REHABILITASI MEDIK Nama :
Umur
:
L / P
VII. PROGRAM REHABILITASI MEDIK Fisioterapi Terapi panas
:............................................................................................................. .............................................................................................................
Terapi dingin
:.............................................................................................................. .............................................................................................................
Stimulasi listrik :.............................................................................................................. .............................................................................................................. Terapi latihan : ............................................................................................................. ............................................................................................................ Okupasi terapi ROM
excercise
ADL Excercise Ortotik prostetik Ortotic
: :
....................................................................................... .......................................................................................
:................................................................................................
Prostetic
: ...............................................................................................
Alat bantu ambulasi
:................................................................................................
Terapi wicara Afasia Dysartria Dysfagia
: ................................................................................................ :................................................................................................. :.................................................................................................
Social medik
:.................................................................................................
Edukasi
:.................................................................................................. ..................................................................................................
TERAPI
Ruang :
No.Rek.Med :
FK UNSRI PALEMBANG
RM.R
14
BAGIAN REHABILITASI MEDIK PROGNOSA / FOLLOW UP
Nama :
Umur
:
L / P
VIII. TERAPI MEDIKAMENTOSA ………………………………………………………………………………………………………. ……………………………………………………………………………………………………… PEMERIKSAAN FISIK Ruang : No.Rek.Med : ………………………………………………………………………………………………………. Nama : Umur : L / P ………………………………………………………………………………………………………. ……………………………………………………………………………………………………… …………………………………………………………………………………………………… IX . PROGNOSA Mmmm -
Medik
:……………………………………………………………………………
Fungsional
:…………………………………………………………………………….
X . FOLLOW UP Tanggal
:…………………………………………………………………………….
Keluhan
: …………………………………………………………………………….
Pemeriksaan Umum
: …………………………………………………………………………….
Keadaan khusus
: …………………………………………………………………………….
Fungsional
: Barthel Index
:
FIM Index
:
Katz index
:
