Follow Up Saraf

RSUD PALEMBANG BARI RM.SRF.1

ANAMNESISRuang : ...................................... No. Rek.Med : ..........................

Nama : ....................................... Umur L/P : ................................

Tanggal :

Dari : pasien sendiri / ayah / ibu / orang lain

Dokter Muda : .......................................

Dokter : ..............................................


PEMERIKSAAN FISIKRuang : ...................................... No. Rek.Med : ..........................

Nama : ....................................... Umur L/P : ................................

A. Status PraesensKesadaran : ......................................Gizi : ......................................Suhu Badan : ......................................Nadi : ......................................Pernapasan : ......................................Tekanan Darah : ......................................Berat Badan : ......................................Tinggi Badan : ......................................

Status PsikisSikap : ......................................Perhatian : ......................................

Status InternusJantung : .....................................................Paru : .....................................................Hepar : .....................................................Lien : .....................................................Anggota Gerak : .....................................................Genetalia : .....................................................

Ekspresi Muka : .....................................................Kontak Psikis : .....................................................

B. Status Neurologis1. Kepala

Bentuk : ...............................................Ukuran : ...............................................Simetris : ...............................................

2. LeherSikap : ........................................Torticollis : ........................................Kaku kuduk : ........................................

Deformitas : ..............................................Tumor : ..............................................Pembuluh darah : ..............................................

C. Syaraf-syaraf Otak1. N. Olfaktorius Kanan

Penciuman : ................................................................Anosmia : ................................................................Hyposmia : ................................................................Parosmia : ................................................................

2. N. OptikusVisus : ................................................................

Campus Visi

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Nama : ....................................... Umur L/P : ................................ Kanan

- Anopsia : ................................................................- Hemianopsia: ................................................................

Fundus oculi- Papil edema : ................................................................- Papil atrofi : ................................................................- Perdarahan retina : ........................................................

3. N. Oculomotorius, Trochlearis, dan Abducen KananDiplopia : ................................................................Celah mata : ................................................................Ptosis : ................................................................Sikap bola mata : .............................................................- Strabismus : ................................................................- Exopthalmus: ................................................................- Enopthalmus: ................................................................- Deviation conjuge : .......................................................Gerakan bola mata : ........................................................Pupil : ................................................................- Bentuk : ................................................................- Diameter : ................................................................- Iso/Anisokor: ................................................................- Midriasis/Miosis : .........................................................- Refleks Cahaya : ...........................................................

• Langsung : ................................................................• Konsensuil : ................................................................• Akomodasi : ................................................................

- Argyl Robetson : ...........................................................

4. N. TrigeminusMotorik Kanan- Menggigit : ................................................................- Trismus : ................................................................- Refleks kornea : ............................................................Sensorik- Dahi : ................................................................- Pipi : ................................................................- Dagu : ................................................................

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5. N. FacialisMotorik Kanan- Mengerutkan dahi : ......................................................- Menutup mata : ..............................................................- Menunjukkan gigi : .......................................................- Lipat nasolabialis : ........................................................- Bentuk muka

• Istirahat : ....................................................................• Bicara/bersiul : ............................................................

Sensorik- 2/3 depan lidah : ........................................................

Otonom- Salivasi : ........................................................................- Lakrimasi : ....................................................................

Chovstek’s sign : .............................................................

6. N. Cochlearis Kanan

Suara bisikan : ................................................................Detik arloji : ................................................................Test Weber : ................................................................Test Rinne : ................................................................

7. N. Vagus dan Glossopharingeous

Arcus pharynx : ..............................................................Uvula : ................................................................Gg. Menelan : ................................................................Suara bicara : ................................................................Denyut jantung : ..............................................................Refleks- Muntah : ................................................................- Batuk : ................................................................- Oculocardiac : ...............................................................- Sinus caroticus : ............................................................

Sensorik- 1/3 belakang lidah : .......................................................

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8. N. Acessorius Kanan- Mengangkat bahu : ........................................................- Memutar kepada : .........................................................

9. N. Hypoglosus Kanan

Menjulurkan lidah : .........................................................Fasikulasi : ................................................................Atrofi papil lidah : ..........................................................Dysatria : ................................................................

Kiri......................................................................................................................................

Kiri............................................................................................................................................................................................................................................................................

D. Columna VertebralisKyphosis : ........................................................................................................................................

Scoliosis : ........................................................................................................................................

Lordosis : ........................................................................................................................................

Gibbus : ........................................................................................................................................

Deformitas : ........................................................................................................................................

Tumor : ........................................................................................................................................

Meningocele: ........................................................................................................................................

Hematoma : ........................................................................................................................................

Nyeri ketok : ........................................................................................................................................



Nama : ....................................... Umur L/P : ................................

E. Badan dan Anggota GerakMotorik

Lengan Kanan- Gerakan : ................................................................- Kekuatan : ................................................................- Tonus : ................................................................- Refleks fisiologis

• Biceps : ................................................................• Triceps : ................................................................• Periost Radius : ...........................................................• Periost Ulna : ..............................................................

- Refleks patologis • Hoffman Tromner : ....................................................

- Trofik : ..........................................................................

Tungkai Kanan- Gerakan : ................................................................- Kekuatan : ................................................................- Tonus : ................................................................- Klonus : ................................................................

• Paha : ................................................................• Kaki : ................................................................

- Refleks fisiologis• KPR : ................................................................• APR : ................................................................

- Refleks patologis • Babinsky : ................................................................• Chaddock : ................................................................• Oppenheim: ................................................................• Gordon : ................................................................• Schaeffer : ................................................................• Rossolimo : ................................................................• Mendel Bechtereyev : ................................................

- Refleks kulit perut• Atas : ................................................................• Tengah : ................................................................• Bawah : ................................................................• Tropik : ................................................................

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Nama : ....................................... Umur L/P : ................................

Sensorik:

F. G A M B A R



Nama : ....................................... Umur L/P : ................................

G. Gejala Rangsang Meningeal Kanan- Kaku kuduk : ................................................................- Kernig : ................................................................- Lassergue : ................................................................- Brudzinsky

• Neck : ................................................................• Cheeck : ................................................................• Symphysis : ................................................................• Leg I : ................................................................• Leg II : ................................................................

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H. Gait dan KeseimbanganGait

- Ataxia : ................................................................- Hemiplegic : ................................................................- Scissor : ................................................................- Propulsion : ................................................................- Histeric : ................................................................- Limping : ................................................................- Steppage : ................................................................- Astasia-abasia : ..............................................................

Keseimbangan- Romberg : .....................................- Dysmetri : .....................................

• Jari - jari : .....................................• Jari - hidung : .....................................• Tumit - tumit : .....................................• Dysdiadochokinesis : ..........................• Trunk ataxia : .....................................• Limb ataxia : .....................................

I. Gerakan Abnormal- Tremor : .......................................................................................................................................- Chorea : .......................................................................................................................................- Athetosis : .......................................................................................................................................- Ballismus : .......................................................................................................................................- Dystoni : .......................................................................................................................................- Myoclonic : .......................................................................................................................................

J. Fungsi Vegetatif- Miksi : .......................................................................................................................................- Defekasi : .......................................................................................................................................- Ereksi : .......................................................................................................................................

K. Fungsi Luhur- Afasia motorik : ................................................................................................................................- Afasia sensorik : ................................................................................................................................- Afasia nominal : ................................................................................................................................- Apraksia : ................................................................................................................................- Agrafia : ................................................................................................................................- alexia : ................................................................................................................................


PEMERIKSAAN PENUNJANG

Ruang : ...................................... No. Rek.Med : ..........................

Nama : ....................................... Umur L/P : ................................Laboratorium Darah : Urine : Faeces :

Liquor Cerebro Spinal - Warna : ................................................................- Kejernihan : ................................................................- Tekanan : ................................................................- Jumlah Sel : ................................................................- Nonne : ................................................................

- Protein : .....................................- Glukose : .....................................- Queckensted : .....................................- Kultur : .....................................- Pandy : .....................................

Pemeriksaan Khusus- Ro. Cranium : ..............................................................................................................................- Ro. Thorax : ..............................................................................................................................- Coll. Vertebralis : ..............................................................................................................................- ElectroEncephaloGraphy : ........................................................................................................................- Arteriography : ..............................................................................................................................- Electrocardiography : ..............................................................................................................................- Pneumigraphy : ..............................................................................................................................- Lain-lain : ..............................................................................................................................

DIAGNOSA KLINIK : ....................................................................................................................

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DIAGNOSA TOPIK : ....................................................................................................................

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DIAGNOSA ETIOLOGI : ....................................................................................................................

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RINGKASANRuang : ...................................... No. Rek.Med : ..........................

Nama : ....................................... Umur L/P : ................................Anamnesis :

Pemeriksaan :

Diagnosa Klinik : ....................................................................................................................

Diagnosa Topik : ....................................................................................................................

Diagnosa Etiologi : ....................................................................................................................

Pengobatan :

Pembuat catatan medik, Dokter Muda,

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Dokter Penanggung Jawab,

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Lembar Follow-Up Dokter Muda

Nama Pasien : ............................... Ruang Rawat : .................................. No. MedRec: ............

Umur : ................. L/P Dokter Muda : .................................

Tanggal / Pkl Perjalanan Penyakit Instruksi / Rencana Therapy

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Follow Up Saraf