STATUS BAGIAN NEUROLOGI FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS PADANG

STATUS BAGIAN NEUROLOGI FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS PADANG NAMA DOKTER MUDA : NO BP : PERIODE SIKLUS : NAMA DPJP :

IDENTITAS PASIEN NAMA UMUR/TGL LAHIR KELAMIN PEKERJAAN NO RM RS TGL PEMERIKSAAN ALAMAT

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STATUS PERKAWINAN NEGERI ASAL AGAMA NAMA IBU KANDUNG SUKU NOMOR HP

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Catatan: 1. Rekam Medis ini hanya dipergunakan selama mengikuti kepaniteraan klinik di bagian yang bersangkutan. 2. Setelah selesai mengikuti kepaniteraan klinik di bagian yang bersangkutan, rekam medis harus dikumpulkan di sekretariat bagian. 3. Dilarang membuka isi rekam medis kecuali untuk kepentingan pendidikan selama di bagian yang bersangkutan.

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FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS BAGIAN ILMU PENYAKIT SARAF REKAM MEDIS AKADEMIS ILMU PENYAKIT SARAF Pemeriksa : NO. BP : Pemeriksaan ke : Kasus ke :

Nama Penderita Alamat Pekerjaan Agama

No. RM : A. DATA DASAR :.................................................. Jenis Kelamin : Lk/Pr :.................................................. Umur :.............thn :.................................................. Pemeriksaan ke :...... :.................................................. Dirawat yang ke :...... Tanggal dirawat :..................

ANAMNESA / ALLO : Keluhan Utama :........................................................................................................................ @ Riwayat Penyakit Sekarang .......................................................................................................................................... . ......................................................................................................................................... . .......................................................................................................................................... .......................................................................................................................................... . ......................................................................................................................................... .. ........................................................................................................................................ ... ....................................................................................................................................... .... ...................................................................................................................................... .... @ Riwayat Penyakit Dahulu .......................................................................................................................................... . ......................................................................................................................................... .. ........................................................................................................................................ ... ....................................................................................................................................... ... @ Riwayat Penyakit Keluarga .......................................................................................................................................... . ......................................................................................................................................... .. ........................................................................................................................................ ... ....................................................................................................................................... ...

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@ Riwayat Pribadi dan Sosial .......................................................................................................................................... . ......................................................................................................................................... .. ........................................................................................................................................ .. PEMERIKSAAN FISIK I. Umum Keadaan Umum : Baik / Sedang / Buruk Nadi : ...Kali/menit Kesadaran : ............................................... Irama : .................. Kooperatif :................................................ Pernafasan :....kali/menit Keadaan Gizi :................................................ Tekanan darah:.......mmHg Tinggi Badan :...........cm Suhu :.........°C Berat Badan : ..........Kg Turgor Kuit :................. Rambut : ............................................... Kulit dan kuku:................. Kelenjer Getah Bening # Leher :........................................................ # Akslla :....................................................... # Inguinal : ....................................................... Torak # Paru : Inspeksi :........................................................ Palpasi :........................................................ Perkusi :........................................................ Auskultasi :........................................................ # Jantung : Inspeksi :........................................................ Palpasi :........................................................ Perkusi :........................................................ Auskultasi :........................................................ Abdomen Inspeksi :........................................................ Palpasi :........................................................ Perkusi :........................................................ Auskultasi :........................................................ Korpus Vertebrae Inspeksi :........................................................ Palpasi :........................................................ II. Status Neurologikus : A. Tanda Rangsangan Selaput Otak Kaku Kuduk :................................................ Brudzinki I Brudzinki II :................................................ Tanda Kernig :................... B. Tanda Peningkatan Tekanan Intrakranial Pupil : Isokor / An-Isokor / Midriasis ........................................:.................................................

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:...................

C. Pemeriksaan Nervus Kranialis N. I Olfaktorius Penciuman l Subjektif l Objektif dengan bahan N. II Optikus Penglihatan l Tajam Penglihatan l Lapangan pandangan l Melihat warna l fundoskopi N.

III

Kanan

Kiri

Kanan

Kiri

Kanan

Kiri

Kanan

Kiri

Kanan

Kiri

Kanan

Kiri

Okulomotorius

Bola mata Ptosis Gerakan bulbus Strabismus Nistagmus Ekso / Endopthalmus Pupil l Bentuk l Reflek cahaya l Reflek akomodasi l Reflek konvergensi N.

IV

Troklearis

Gerakan mata kebawah Sikap bulbus Diplopia N.

VI

Abdusen

Gerakan mata kelateral Sikap bulbus Diplopia N.

V

Trigeminus

Motorik l Membuka mulut l Menggerakkan rahang

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l Menggigit l Mengunyah Sensorik l Divisi opthalmika ² Reflek kornea ² sensibilitas l Divisi maksila ² Reflek masseter ² Sensibilitas l Divisi mandibula ² Sensibiltas N.

VII

Fasialis Kanan

Kiri

Kanan

Kiri

Kanan

Kiri

Raut wajah Sekresi air mata Fisura palpebra Menggerakkan dahi Menutup mata Mencibir / bersiul Memperlihatkan gigi Sensasi lidah 2/3 Hiperakusis N.

VIII

Vestibularis

Suara berisik Detil arloji Rinne test Webwt test Scwabach test l Memanjang l Memendek Nistagmus l Pendular l Vertikal l Slklikal Pengaruh posisi kepala N.

IX

Glossopharingeus

Sensasi lidah 1/3 belakang Reflek muntah/ Gag reflek

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N.

X

Vagus Kanan

Kiri

Kanan

Kiri

Kanan

Kiri

Arkus faring Uvula Menelan Artikulasi Suara Nadi N.

XI

Asesorius

Menoleh kekanan Menoleh kekiri Mengangkat bahu kekanan Mengangkat bahu kekiri N.

XII

Hipoglosus

Kedudukan lidah dalam Kedudukan lidah dijulurkan Tremor Fasikulasi Atrofi D.

Pemeriksaan Koordinasi dan Keseimbangan Keseimbangan : Romberg test Romberg test dipertajam Stepping gait Tandem gait Koordinasi : Jari-jari Hidung-jari Pronasi-supinasi Test tumit lutut Rebound phenomen

E.

Pemeriksaan Fungsi Motorik A. Badan Respirasi Duduk B. Berdiri dan berjalan

Gerakan spontan Tremor Atetosis

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C. Eksternitas

Mloklonik Khorea Superior Kanan Kiri

Kanan

Inferior Kiri

Gerakan Kekuatan Trofi Tonus F.

Pemeriksaan Sensibilitas Sensibilitas taktil Sensibilitas nyeri Sensibilitas termis Sensibilitas sendi dan posisi Sensibilitas getar Sensibilitas kortikal stereognosis Pengenalan 2 titik Pengenalan rabaan

G. Sistem Refleks 1. Fisiologis Kornea Berbamgkis Laring Maseter Dinding perut l Atas l Tengah l Bawah 2. Patologis Lengan Hoffman - Tromner

Kanan

Kiri

Kanan Biseps Triseps APR KPR Bulbokavemosus Cremaster Sfingter Tungkai Babinski Chaddoks Oppenhelm Gordon Schaeffer Klonus paha Klonus kaki

3. Fungsi Otonom l Miksi : l Defekasi : l Sekresi keringat :

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Kiri

4. Fungsi Luhur Kesadaran l Reaksi bicara l Fungsi intelek l Reaksi emosi

Tanda Dementla l Reflek glabela l Reflek snout l Reflek mengisap l Reflek memegang l Reflek palmomental

PEMERIKSAAN LABORATORIUM Darah : # Rutin :........................................................... ............................................................ ............................................................ ............................................................ # kimia klinik :........................................................... ............................................................ ............................................................ Urine :............................................................ ............................................................. ............................................................. Feses :........................................................... ............................................................ ............................................................. RENCANA PEMERIKSAAN TAMBAHAN 1. ........................................................................................ 2. ........................................................................................ 3. ........................................................................................ 4. ........................................................................................ 5. ........................................................................................ B. MASALAH DIAGNOSIS # Diagnosis Klinis # Diagnosis topik # Diagnosis stiologis Diagnosis Sekunder

:................................................................................................... :................................................................................................... :................................................................................................... :................................................................................................... :...................................................................................................

DIFERENSIAL DIAGNOSA # ......................................................................................................................................... # .........................................................................................................................................

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PROGNOSA ................................................................................................................... ................................................................................................................... ................................................................................................................... C. PEMECAHAN MASALAH TERAPI # Umum / suportif ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... .............................................................................................................................. # Khusus .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. RINGKASAN A. DATA DASAR l Anamnesa

l Pemeriksaan

B. MASALAH Assesment

: Subjektif

: Objektif

:

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C. PEMECAHAN MASALAH Plan :

FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS BAGIAN ILMU PENYAKIT SARAF RESEP Nama dokter muda : Tanggal :

R/

Nama Pasien

:

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Umur : Alamat : FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS BAGIAN ILMU PENYAKIT SARAF CATATAN KEMAJUAN PENDERITA (FLOW CHART) HARI/ TANGGAL

PERKEMBANGAN

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TERAPI TANGAN

DAN

TANDA

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