Status Ujian Rehab.medik

FK. UNSRI PALEMBANG RM. R BAGIAN REHABILITASI MEDIK

ANAMNESISRUANG : ............................No. REK. MED:...............................

NAMA: ............................UMUR / JK:.............. thn / L / P

ALAMAT: ..........................................AGAMA:...............................

PEKERJAAN: ..........................................STATUS PERKAWINAN:...............................

TGL. PEMERIKSAAN: ..........................................Dokter Muda:...............................

I. ANAMNESIS

1. KELUHAN UTAMA

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2. RIWAYAT PENYAKIT SEKARANG.....................................................................................................................................

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3. RIWAYAT PENYAKIT / OPERASI DAHULU

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4. RIWAYAT PENYAKIT PADA KELUARGA.....................................................................................................................................

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5. RIWAYAT PEKERJAAN.....................................................................................................................................

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6. RIWAYAT SOSIAL EKONOMI.....................................................................................................................................

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PEMERIKSAAN

FISIKRUANG:................................NO. MED. REK:..................................

NAMA:.................................Umur / JK:............ .... thn / L / P

II. PEMERIKSAAN FISIK

A. PEMERIKSAAN UMUM

Keadaan Umum : Baik / Sedang / BurukKesadaran : G C STinggi 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 : / mmHg ( Nadi : x / menit ( Pernafasan : x / menit ( Suhu : o CKulit

Status Psikis ( Sikap : Orientasi : ........................... ( Ekspresi wajah : Perhatian : ........................... ( Ekspresi wajah :

PEMERIKSAAN

FISIKRUANG:................................NO. MED. REK:.................................

NAMA:................................Umur / JK:............ .... thn / 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. KepalaBentuk : ............................................................................................................Ukuran : ............................................................................................................Posisi

( Mata : ............................................................................................................ ( Hidung : ............................................................................................................ ( Telinga : ............................................................................................................ ( Mulut : ............................................................................................................ ( Wajah : simetris / asimetrisGerakan abnormal : ............................................................................................................

PEMERIKSAAN



D. Leher Inspeksi : ........................................................................................................ Palpasi : ........................................................................................................ Luas gerak sendi

Ante / Retrofleksi ( n 65 / 50 ) : .............. / ...............

Laterofleksi ( D / S ) ( n 40 / 40 ) : ............. / ...............

Rotasi ( D / S ) ( n 45 / 45 ) : ............. / ...............

Test provokasi

Lhermitte test / Spurling : ................ Test Valsava : .................. Distraksi test : ................ Test Nafziger : ...................

E. Thorak

Bentuk : ....................................................................................................Pemeriksaan Ekspansi Thorak : Ekspirasi Maksimum ...... cm. Inspirasi maksimum ..... cm

Paru Paru ( Inspeksi : ................................................................................................... ( Palpasi : ................................................................................................... ( Perkusi : ................................................................................................... ( Auskultasi : ....................................................................................................Jantung

( Inspeksi : ................................................................................................... ( Palpasi : ................................................................................................... ( Perkusi : ................................................................................................... ( Auskultasi : ...................................................................................................Abdomen ( Inspeksi : .................................................................................................... ( Palpasi : .................................................................................................... ( Perkusi : .................................................................................................... ( Auskultasi : .....................................................................................................

PEMERIKSAAN



G. Trunkus

Inspeksi : Simetris

( Deformitas : ...................................................................................................................... ( Lordosis : ...................................................................................................................... ( Scoliosis : ...................................................................................................................... ( Gibbus : ...................................................................................................................... ( Hairy spot : ...................................................................................................................... ( Pelvic Tilt : ...................................................................................................................... Palpasi :

( Spasme otot otot para vertebrae : ............................................................................ ( Nyeri tekan ( lokasi ) : ........................................................................... Luas gerak sendi lumbosacral

( Ante / Retrofleksi ( 95 / 35 ) : ............................................................................ ( Laterofleksi ( D / S ) ( 40 / 40 ) : ............................................................................ ( Rotasi ( D / S ) ( 35 / 35 ) : ............................................................................ Test provokasi

( Valsava test : ................. Test Laseque : ....... / ....... Test Baragard dan sicard : ...... / ....... ( Niffziger test : ................. Test SLR : ....... /........ Test Oconnell : ....... / ...... ( FNST : ......... / ........ Test Patrick : ........ / ........ Test Kontra Patrick : ...... / ....... ( Test Gaenslen : ........ / ......... Test Thomas : ........ / ........ Test Ober s : ...... / .......

( Nachalas knee flexion test : ........ / ......... Mc. Bride sitting test : ....... / ......

( Yeomann s hyprextension : ........ / ......... Mc. Bridge toe to mouth sitting test : ....... / ......

( Test Schober : ....................................................................................................................... H. Anggota Gerak Atas Inspeksi Kanan Kiri ( Deformitas : ....................... .................... ( Edema : ....................... ....................

( Tremor : ....................... ....................

( Nodus Heberden : ....................... ...................

PEMERIKSAAN

FISIK / NEUROLOGIRUANG:................................NO. MED. REK:.................................


Neurologi

Motorik Dextra Sinistra

Gerakan ................... ................... Kekuatan ................... ................... Abduksi lengan ................... ................... Fleksi bahu ................... ................... Ekstensi siku ................... ................... Abduksi jari tangan ................... ................... Tonus ................... ................... Tropi ................... ................... Refleks fisiologis

Refleks tendon bisep ................... ................... Refleks tendon triseps ................... ................... Refleks patologis

Hoffman ................... ................... Tromner ................... ................... Sensorik

Protopatik ................... ................... Proprioseptik ................... ................... Vegetatif ................... ...................Penilaian fungsi tangan Dextra Sinistra Anatomical ................... ...................Grips ................... ...................Spread ................... ...................Palmar abduct ................... ...................Pinch ................... ...................Lumbrical ................... ...................

PEMERIKSAAN

FISIK / LGSRUANG:................................NO. MED. REK:.................................


Luas gerak sendi

Aktif

Dextra

Aktif

Sinistra

Pasif

Dextra

Pasif

Sinistra

Abduksi bahu

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Adduksi bahu

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Fleksi bahu

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Ekstensi bahu

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Endorotasi bahu ( f0 )................

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Eksorotasi bahu ( f0 )................

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Endorotasi bahu ( f90 )Eksorotasi bahu ( f90 )Fleksi siku ................

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Ekstensi siku ................

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Ekstensi pergelangan tangan

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Fleksi pergelangan tangan

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Supinasi

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Pronasi

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Test Provokasi

KananKiri

Yergason test

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Apley scratch test

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Moseley test

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Adson manuver

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Tinel test

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Phalen test

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Prayer test

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Finkelstein

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Promet test

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PEMERIKSAAN



I. Anggota Gerak BawahInspeksi

Kanan

Kiri

Deformitas

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Edema

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Tremor

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Palpasi

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Nyeri tekan ( lokasi )

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Diskrepansi

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Neurologi

Motorik

Kanan Kiri Gerakan

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Kekuatan

Fleksi paha

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Ekstensi paha

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Ekstensi lutut

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Fleksi lutut

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Dorsofleksi pergelangan kaki

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Dorsofleksi ibu jari kaki

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Plantar fleksi pergelangan tangan

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Tonus

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Tropi

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Reflkes fisiologis

Refleks tendo patella

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Refleks tendo achilles

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Refleks patologi

Babinsky

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Chaddock

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PEMERIKSAAN

FISIK / LGSRUANG:................................NO. MED. REK:.................................


Sensorik

Kanan

Kiri

Protopatik

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Proprioseptik

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Vegetatif

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Luas gerak sendiAktif DextraAktif SinistraPasif DextraPasif SinistraFleksi paha

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Ekstensi paha

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Endorotasi paha

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Adduksi paha

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Abduksi paha

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Fleksi lutut

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Ekstensi lutut

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Dorsofleksi pergelangan kaki

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Plantar fleksi pergelangan kaki

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Inversi kaki

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Eversi kaki

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Test Provokasi

Kanan

Kiri

Stres test

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Drawers test

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Test tunel pada sendi lutut

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Test homan

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Test lain lain

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PEMERIKSAAN



III. Pemeriksaan - Pemeriksaan lainnya

Pemeriksaan refleks refleks primitive pada anak anak dengan gangguan SSP

Righting reaction

:............................................................................... Reaksi keseimbangan

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Pemeriksaan lainnya

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Bowel test / Bladder test

Sensorik perianal

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Motorik sphinter ani eksternus

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BCR ( Bulbocapernosis Refleks )

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Fungsi luhur

Afasia

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Apraksia

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Agrafia

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Alexia

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IV. PEMERIKSAAN PENUNJANGA. RADIOLOGIS : .....................................................................................................................................................

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B. LABORATORIUM : .....................................................................................................................................................

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C. LAIN LAIN CT - Scan / MRI

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RESUME

RUANG:................................NO. MED. REK:.................................


V. RESUME

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EVALUASI / DIAGNOSISRUANG:................................NO. MED. REK:.................................


VI. EVALUASI

NO

Level ICF

Kondisi saat ini

Sasaran

1

Struktur dan fungsi tubuh

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Aktivitas

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Partisipasi

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Catatan : ICF ( International Clasification of Function / WH0 2002 )DIAGNOSIS KLINIS

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PEMERIKSAAN



VII. PROGRAM REHABILITASI MEDIKFisioterapi

Terapi panas

:

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Terapi dingin

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Stimulasi listrik

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Terapi latihan

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Okupasi Terapi

ROM exercise

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...........................................................................................................ADL exercise

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...........................................................................................................Ortotik Prostetik

Ortotic

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Prostetic

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Alat bantu ambulasi

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Terapi wicara

Afasia

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Dysartria

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Dysfagia

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Social Medik

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Edukasi

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PEMERIKSAAN



VIII. TERAPI MEDIKAMENTOSA

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IX. PROGNOSA

Medik : ........................................................................................................................... Fungsional : ...........................................................................................................................X. FOLLOW UP

Tanggal : .......................................................................................................................... Keluhan : .......................................................................................................................... Pemeriksaan umum : ......................................................................................................... Keadaan khusus : ......................................................................................................... Fungsional : Barthel index : FIM index :

Katz index :

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Status Ujian Rehab.medik