Status Ujian Rehabilitasi Medik

8/17/2019 Status Ujian Rehabilitasi Medik

1/14

FK UNSRI PALEMBANG RM.R

BAGIAN REHABILITASI MEDIK

ANAMNESIS Ruang :……………………….. No.Rek.Med :……………………………

Nama :……………………….. Umur / Jeni :……………………… L / P

A!ama" :……………………………………………. Agama :……………………

Peker#aan : …………………………………………… S"a"u $erka%inan :……………………

&angga! $emerikaan :……………………………………. 'ok"er muda :……………………

(

1. ANAMNESIS

2. KELUHAN UTAMA

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3. RIWAYAT PENYAKIT SEKARANG………………………………………………………………………………………………….

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4. RIWAYAT PENYAKIT / OPERASI DAHULU………………………………………………………………………………………………….

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5. RIWAYAT PENYAKIT PADA KELUARGA

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). RIWAYAT PEKERJAAN………………………………………………………………………………………………

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7. RIWAYAT SOSIAL EKONOMI

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2/14



PEMERIKSAAN FISIK Ruang : No.Rek.Med :

Nama : Umur : L / P


*

II. PEMERIKSAAN FISIK

A. Pemerikaan Umum

Keadaan Umum : +aik / edang / +uruk

Keadaran : G , S :

&inggi Badan / Bera" Badan : -m / kg BMI :

,ara +er#a!an / Gai"

♠ An"a!gik gai" :.............................................................................................

♠ emi$aree gai" :……………………………………………………………

♠ S"e$$age gai" : .............................................................................................

♠ Parkinon gai" : .............................................................................................

♠ &rede!en+erg gai" : .............................................................................................

♠ add!e gai" : .............................................................................................

♠ Lain 0 !ain : .............................................................................................

Baa!a / "#$a%a

Komunikai 1er+a! : .............................................................................................

Komunikai non1er+a!: .............................................................................................

Ta&'a (#)a*

&ekanan dara2 : / mmg

Nadi : 3 / meni"

Perna4aan : 3 / meni"

Su2u : ,

K+*#) :

S)a)+! P!#,#!

Sika$ : 5rien"ai :........................................

Ek$rei %a#a2 : Per2a"ian :........................................


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Nama : Umur : L / P

6

B. Sa%a- !a%a- )a,

Ner1u kanan kiri

I. N.5!4ak"oriu ……………... .................

II. N.5$"i-u ....................... .................

III. N.5--u!omo"oriu ....................... ..................

I7. N.&ro-2!eari ....................... .................

7. N.&rigeminu ....................... .................

7I. N.A+du-en ....................... ...................

7II. N.Fa-ia!i ...................... ...................

7III. N.7e"i+u!ari ...................... ...................

I8. N.G!oo$2ar9ngeu ...................... ....................

8. N.7agu ....................... ....................

8I. N.a--eoriu ....................... ....................

8II. N.9$og!ou ........................ ....................

,. Ke$a!a

Ben"uk : ............................................................................................................

Ukuran : ............................................................................................................

Poii :.............................................................................................................

Ma"a :.............................................................................................................

idung :.............................................................................................................

&e!inga :............................................................................................................ Mu!u" : ............................................................................................................

a#a2 : ime"ri / aime"ri gerakan a+norma! : ………………


4/14




Nama : Umur : L / P


;

'. Le2er

In$eki :…………………………………………………………………………………

Pa!$ai : ………………………………………………………………………………..

Lua Gerak Sendi

An"e / re"ro4!eki < n )= / => ? : ………/………….

La"ero4!eki < '/S ? < n ;> / ;> ? :………/………….

Ro"ai < '/S ? < n ;= / ;= ? : ………/………..

&e" $ro1okai

L2ermi""e "e" / S$ur!ing :……………… &e" 7a!a!1a :……………………….

'i"raki "e" :……………… &e" Na4@iger :……………………….

E. &2orak

Ben"uk :……………………………………………………….

Pemerikaan Ek$ani &2orak : Ek$irai makimum .......,m In$irai Makimum ..........-m

Pa%+0 a%+

In$eki : …………………………………………………………………………..

Pa!$ai :…………………………………………………………………………..

Perkui : ………………………………………………………………………….

Auku!"ai : ……………………………………………………………………………..

Ja&)+&

In$eki : ……………………………………………………………………………..

Pa!$ai : …………………………………………………………………………….

Perkui : ……………………………………………………………………………..

Auku!"ai : ……………………………………………………………………………..

F. A+domen In$eki : …………………………………………………………………………….

Pa!$ai : …………………………………………………………………………….

Perkui : …………………………………………………………………………….

Auku!"ai : ……………………………………………………………………………


5/14



Nama : Umur : L / P

Ruang : No.Rek.Med :

=

G. &runku

In$eki :

Sime"ri :………………………………………………………………………….

'e4ormi"a :…………………………………………………………………………..

Lordoi :…………………………………………………………………………..

S-o!ioi :………………………………………………………………………….

Gi++u :………………………………………………………………………….

air9 $o" :…………………………………………………………………………..

Pe!1i- &i!" :…………………………………………………………………………

Pa!$ai :

S$ame o"o"o"o" $ara 1er"e+rae :…………………………………………………………

N9eri "ekan < !okai ? :…………………………………………………………

Lua gerak endi !um+oakra!

An"e /re"ro 4!eki


6/14



PEMERIKSAAN FISIK / NEUR5L5GI Nama : Umur : L / P

)

N+%*#

Mo"orik 'e3"ra Sini"ra

Gerakan .............................. ........................................

Kekua"an .............................. ........................................

A+duki !engan .............................. ........................................

F!eki iku ............................... ........................................

Ek"eni iku ............................... ........................................

Ek"eni ri" ............................... .........................................

F!eki #ari #ari "angan ............................... ........................................

A+duki #ari "angan ............................... ........................................

&onu ............................... .........................................

&ro$i ............................... ........................................

Re4!ek Fiio!ogi

Re4!ek "endon +ie$ ............................... .......................................

Re4!ek "endon "rie$ .............................. ......................................

Re4!ek Pa"o!ogi

o44man ............................... .......................................

&romner .............................. ........................................

Senorik

Pro"o$a"ik :.....................................................................................................................

Pro$rioe$"ik :....................................................................................................................

7ege"a"i4 :....................................................................................................................

P*a#a& -+&!# )a&a& kanan kiriAna"omi-a! ................ ..................

Gri$ ................ ..………….

S$read …………. .…………..

Pa!mar a+du-" …………. ……………

Pin-2 …………. …………....

Lum+ri-a! .……….... …………….


7/14



PEMERIKSAAN FISIK / LGS Ruang : No.Rek.Med :

Nama : Umur : L / P

L+a! %a, !&'# Ak"i4 Ak"i4 Pai4 Pai4

'e3ra ini"ra 'e3ra Sini"ra

A+duki +a2u ………… ............. .................. ................

Adduki +a2u ………… ……….. ................. ................

F!eki +a2u .............. ............... .................. ................

E3"eni +a2u ............... ................ ................. ................

Endoro"ai +a2u ? ................ ................ ................. ..................

Ekoro"ai +a2u ? ................. ................. .................. ...................

Endora"ai +a2u ? ................. ................. .................. ..................

Ekoro"ai +a2u ? .................. ................. ................... ...................

F!eki iku ................. ................ ................... ...................

Ek"eni iku .................. .................. .................. ...................

Ek"eni $erge!angan "angan .................. .................. .................. ....................

F!eki $erge!angan "angan ................... .................. .................. ....................

Su$inai .................... ………….. ………….. …………….

Pronai …………… ………….. ………….. …………….

&e" Pro1okai kanan kiri

Dergaon "e" : ………………… ………………….

A$!e9 -ra"-2 "e" : ………………… …………………

Moe!e9 "e" : ………………… ………………….

Adon manu1er : ………………… …………………

&ine! "e" : ………………… …………………

P2a!en "e" : ………………… ………………….

Pra9er "e" : ……………….. …………………

Finke!"ein : ……………….. ………………..

Prome" "e" : ………………… …………………


8/14




Nama : Umur : L / P

I. Anggo"a Gerak Ba%a2

In$eki kanan kiri

'e4ormi"a : ……………….. ………………

Edema : ………………. .......................

&remor : ......................... .......................

Pa!$ai

N9eri "ekan < !okai ? : ........................... ..........................

'ikre$ani : ........................... ..........................

N+%*#

Mo"orik kanan kiri

Gerakan ........... ...........

Kekua"an

F!eki $a2a ............ ..............

Ek"eni $a2a ............ ..............

Ek"eni !u"u" ............ ...............

F!eki !u"u" ............. ...............

'oro4!eki $erge!angan kaki ............. ................

'oro4!eki i+u #ari kaki .............. ................

P!an"ar 4!eki $erge!angan kaki .............. ...............

&onu ............... ................

&ro$i ................ ...................

Re4!ek Fiio!ogi

Re4!ek "endo $a"e!!a ................ …………...

Re4!ek "endo a-2i!!e ………… …………..

Re4!ek $a"o!ogi

Ba+ink9 …………… ……………

,2addo-k …………… ……………


9/14



PEMERIKSAAN FISIK / LGS Ruang : No.Rek.Med :

Nama : Umur : L / P

S&!%#, kanan kiri

Pro"o$a"ik : ……………. ……………….

Pro$rioe$"ik : ……………. ………………

)a)#- : ……………. ………………

L+a! %a, !&'#

Lua gerak Ak"i4 Ak"i4 Pai4 Pai4

Sendi 'e3"ra Sini"ra 'e3"ra Sini"ra

F!eki $a2a ……… ………. ………… ………..

Ek"eni $a2a ……… ………. ………… ………..

Endoro"ai $a2a ……… ………. ………… ………..

Adduki $a2a ……… ………. ………… ………..

A+duki $a2a ……… ………. ………… ………..

F!eki !u"u" ……… ………. ………… ………..

Ek"eni !u"u" ……… ………. ………… ………..

'oro4!eki $erge!angan kaki ……… ………. ………… ……….

P!an"ar 4!eki $erge!angan kaki ……… ………. ………… ……….

In1eri kaki ……… ………. ………… ……….

E1eri kaki ……… ………. ………… ……….

T!) P%(,a!# !&'# *+)+) ,a&a& ,#%#

S"re "e" ................ ...................

'ra%erC "e" ................ ....................

&e" &une! $ada endi !u"u" ................. ....................

&e" oman ................. ....................

&e" !ain 0 !ain ................... ....................


10/14




Nama : Umur : L / P

(>

III. P%#,!aa&0 %#,!aa& *a#&&6a

Pemerikaan re4!ek 0re4!ek $rimi"i1e $ada anak 0anak dengan gangguan SSP

Rig2"ing rea-"ion :…………………………………………………

Reaki keeim+angan :…………………………………………………

Pemerikaan !ainn9a :…………………………………………………

Bo%e! "e" / B!adder "e"

Senorik $eri ana! :………………………….

Mo"orik $2in-"er ani ek"ernu :………………………….

B,R < Bu!+o-a1ernoi Re4!ek :………………………….

Fungi !u2ur

A4aia :………………………………………………….

A$rakia :………………………………………………….

Agra4ia :…………………………………………………

A!e3ia :………………………………………………….

I. PEMERIKSAAN PENUNJANG

A. Radio!ogi :

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B. La+ora"orium :

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,. Lain 0!ain ,& 0 S-an / MRI :

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11/14



RESUME Ruang : No.Rek.Med :

Nama : Umur : L / P

((

. RESUME

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12/14



EALUASI / DIAGNOSIS Ruang : No.Rek.Med :

Nama : Umur : L / P

(*

I. EALUASI

N5 Le1e! I,F Kondii aa" ini Saaran

( S"ruk"ur dan 4ungi "u+u2 ……………………………..

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* Ak"i1i"a ……………………………..

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6 Par"ii$ai ……………………………..……………………………..

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,a"a"n : I,F In"erna"iona! ,!ai4i-a"ion o4 Fun-"ion < 5 *>>* ?

DIAGNOSIS KLINIS

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13/14



PROGRAM REHABILITASI Ruang : No.Rek.Med :

Nama : Umur : L / P

(6

II. PROGRAM REHABILITASI MEDIK

F#!#)%a#

&era$i $ana :.............................................................................................................

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&era$i dingin :.............................................................................................................

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S"imu!ai !i"rik :..............................................................................................................

.............................................................................................................. &era$i !a"i2an : .............................................................................................................

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O,+a!# )%a#

R5M e3-er-ie : .......................................................................................

A'L E3-er-ie : .......................................................................................

O%))#, %!))#, 5r"o"i- :................................................................................................

Pro"e"i- : ...............................................................................................

A!a" +an"u am+u!ai :................................................................................................

T%a# #$a%a

A4aia : ................................................................................................

'9ar"ria :.................................................................................................

'94agia :.................................................................................................

S$#a* '#, :.................................................................................................

E'+,a!# :..................................................................................................

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14/14



TERAPI

PROGNOSA / FOLLOW UP

Ruang : No.Rek.Med :

Nama : Umur : L / P


Nama : Umur : L / P

Mmmm

(;

III. TERAPI MEDIKAMENTOSA

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I8 . PROGNOSA

M'#, 9……………………………………………………………………………

0 F+&!#&a* 9…………………………………………………………………………….

8 . FOLLOW UP

Ta&a* 9…………………………………………………………………………….

K*+a& 9 …………………………………………………………………………….

P%#,!aa& U+ 9 …………………………………………………………………………….

Ka'aa& ,+!+! 9 …………………………………………………………………………….

F+&!#&a* 9 Ba%)* I&': 9

FIM I&': 9

Ka); #&': 9

Documents

Status Ujian Rehabilitasi Medik