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
FISIKRUANG:................................NO. MED. REK:.................................
NAMA:................................Umur / JK:............ .... thn / L / P
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
FISIKRUANG:................................NO. MED. REK:.................................
NAMA:................................Umur / JK:............ .... thn / 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 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:.................................
NAMA:................................Umur / JK:............ .... thn / L / P
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:.................................
NAMA:................................Umur / JK:............ .... thn / L / P
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
FISIKRUANG:................................NO. MED. REK:.................................
NAMA:................................Umur / JK:............ .... thn / L / P
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:.................................
NAMA:................................Umur / JK:............ .... thn / L / P
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
FISIKRUANG:................................NO. MED. REK:.................................
NAMA:................................Umur / JK:............ .... thn / L / P
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:.................................
NAMA:................................Umur / JK:............ .... thn / L / P
V. RESUME
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EVALUASI / DIAGNOSISRUANG:................................NO. MED. REK:.................................
NAMA:................................Umur / JK:............ .... thn / L / P
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
FISIKRUANG:................................NO. MED. REK:.................................
NAMA:................................Umur / JK:............ .... thn / L / P
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
FISIKRUANG:................................NO. MED. REK:.................................
NAMA:................................Umur / JK:............ .... thn / L / P
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 :
Recommended