Status Ujian Rehab.medik

July 11, 2016 | Author: FebriWijaya | Category: Types, Legal forms

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FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

ANAMNESIS

RUA NG

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

No. REK. MED

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

NAM A

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

UMUR / JK

: .............. L/P

AGAMA

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

thn /

ALAMAT

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

PEKERJAAN

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

STATUS PERKAWIN AN

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

TGL. PEMERIKSAAN

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

Dokter Muda

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

I. ANAMNESIS 1. KELUHAN UTAMA ...................................................................................................... ............................... ...................................................................................................... ............................... ...................................................................................................... ............................... 2. RIWAYAT PENYAKIT SEKARANG ...................................................................................................... ............................... ...................................................................................................... ............................... ...................................................................................................... ............................... ...................................................................................................... ............................... ...................................................................................................... ............................... 3. RIWAYAT PENYAKIT / OPERASI DAHULU ...................................................................................................... ............................... ...................................................................................................... ............................... ...................................................................................................... ............................... ...................................................................................................... ............................... ......................................................................................................

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

............................... 4. RIWAYAT PENYAKIT PADA KELUARGA ...................................................................................................... ............................... ...................................................................................................... ............................... ...................................................................................................... ............................... 5. RIWAYAT PEKERJAAN ...................................................................................................... ............................... ...................................................................................................... ............................... ...................................................................................................... ............................... 6. RIWAYAT SOSIAL EKONOMI ...................................................................................................... ............................... ...................................................................................................... ............................... ...................................................................................................... ...............................

PEMERIKSAA N FISIK

RUA NG

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

NO. MED. REK

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

NAM A

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

Umur / JK

: ............ .... thn / L/P

II. PEMERIKSAAN

FISIK

A. PEMERIKSAAN UMUM Keadaan Umum

: Baik / Sedang / Buruk

Kesadaran

: G

Tinggi Badan / Berat Badan BMI

:

C

S

...............

cm / ................

kg

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

Cara berjalan / Gait  gait ..............

Antalgik : ..............................................................................

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK



Hemiparese

gait

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

........ 

Steppage

gait

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

............ 

Parkinson

gait

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

........... 

Tredelenberg

gait

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

...... 

Waddle

gait

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

............... 

Lain -

lain

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

.................. Bahasa / Bicara 

Komunikasi

verbal

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

........... 

Komunikasi

nonverbal

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

.......... Tanda Vital 

Tekanan darah



Nadi



Pernafasan



Suhu

: : : :

Kulit Status

Psikis



Sikap

/

:

mmHg x /

x o

menit

/ menit

C

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

Orientasi 

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

Ekspresi

wajah

:

Perhatian : ........................... 

Ekspresi

PEMERIKSAA N FISIK

wajah

:

RUA NG

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

NO. MED. REK

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

NAM A

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

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 .................

.................

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

XI. N. Accesorius

.................

................. XII. N. Hypoglosus

.................

................. C. Kepala Bentuk

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

....................................... Ukuran

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

....................................... Posisi  Mata

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

.............................  Hidung

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

.............................  Telinga

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

.............................  Mulut

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

............................. 

Wajah

: simetris / asimetris

Gerakan abnormal : ..................................................................................... .......................

PEMERIKSAA N FISIK

RUA NG

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

NO. MED. REK

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

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

NAM A

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

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 .........................

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

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

 Perkusi

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

.........................  Auskultasi

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

........................ Jantung  Inspeksi

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

........................  Palpasi

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

........................  Perkusi

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

.........................  Auskultasi

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

....................... Abdomen  Inspeksi

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

.......................  Palpasi

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

.......................  Perkusi

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

........................  Auskultasi

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

........................ PEMERIKSAA N RUA : ........................

NO. MED.

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

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

NG FISIK

NAM A

........

REK

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

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 /

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

40 )

: ............................................................................  Rotasi ( D / S ) ( 35 /

35 )

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

Test provokasi  Valsava test

: ................. Test Laseque : ....... / ....... Test

Baragard dan sicard : ...... / .......  Niffziger test O’connell

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

Test SLR

: ....... /........ Test

: ....... / ......

 FNST

: ......... / ........ Test Patrick

Test Kontra Patrick

: ........ / ........

: ...... / .......

 Test Gaenslen : ........ / ......... Test Thomas Ober ‘ s

: ........ / ........ Test

: ...... / .......

 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 Kiri  Deformitas ....................  Edema ....................  Tremor ....................  Nodus Heberden ...................

PEMERIKSAA N FISIK / NEUROLOGI

Kanan :

.......................

:

.......................

:

.......................

:

.......................

RUA NG

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

NO. MED. REK

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

NAM A

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

Umur / JK

: ............ .... thn / L/P

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

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 ...................

...................

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

Vegetatif

...................

................... Penilaian fungsi tangan

Dextra

Sinistra Anatomical

...................

................... Grips

...................

................... Spread

...................

................... Palmar abduct

...................

................... Pinch

...................

................... Lumbrical

...................

...................

PEMERIKSAA N FISIK / LGS

RUA NG

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

NO. MED. REK

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

NAM A

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

Umur / JK

: ............ .... thn / L/P

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

Luas gerak sendi

Aktif

Aktif

Pasif

Pasif

Abduksi bahu

Dextra ...............

Sinistra ...............

Dextra ...............

Sinistra ...............

Adduksi bahu

. ...............

...............

. ...............

...............

Fleksi bahu

. ...............

...............

. ...............

...............

Ekstensi bahu

. ...............

...............

. ...............

...............

Endorotasi bahu

( f0 )

. ...............

...............

. ...............

...............

Eksorotasi bahu

( f0 )

. ...............

...............

. ...............

...............

Endorotasi bahu

( f90 )

Eksorotasi bahu

( f90 )

.

.

Fleksi siku

...............

...............

...............

...............

Ekstensi siku

. ...............

...............

. ...............

...............

Ekstensi pergelangan tangan

. ...............

...............

. ...............

...............

Fleksi pergelangan tangan

. ...............

...............

. ...............

...............

Supinasi

. ...............

...............

. ...............

...............

Pronasi

. ...............

...............

. ...............

...............

. Test Provokasi

. Kanan

Kiri

-

Yergason test

:

...............

...............

-

Apley scratch test

:

...............

...............

-

Moseley test

:

...............

...............

-

Adson manuver

:

...............

...............

-

Tinel test

:

...............

...............

-

Phalen test

:

...............

...............

-

Prayer test

:

...............

...............

-

Finkelstein

:

...............

...............

-

Promet test

:

...............

...............

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

PEMERIKSAA N FISIK

RUA NG

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

NO. MED. REK

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

NAM A

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

Umur / JK

: ............ .... thn / L/P

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

I. Anggota Gerak Bawah Inspeksi - Deformitas - Edema - Tremor Palpasi - Nyeri tekan ( lokasi ) - Diskrepansi Neurologi Motorik Gerakan Kekuatan Fleksi paha Ekstensi paha Ekstensi lutut Fleksi lutut Dorsofleksi pergelangan

Kanan ................... ................... ................... ................... ................... ...................

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

Kanan ...................

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

................... ................... ................... ................... ...................

.................. .................. .................. .................. ..................

Dorsofleksi ibu jari

...................

..................

Plantar fleksi

...................

..................

................... ...................

.................. ..................

...................

..................

...................

..................

................... ...................

.................. ..................

: : : : :

kaki kaki pergelangan tangan Tonus Tropi Reflkes fisiologis Refleks tendo patella Refleks tendo achilles Refleks patologi Babinsky Chaddock

PEMERIKSAA N FISIK / LGS

RUA NG

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

NO. MED. REK

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

NAM A

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

Umur / JK

: ............ .... thn / L/P

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

Sensorik Protopatik Proprioseptik Vegetatif

Kanan ................ ................ ................

Luas gerak sendi

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

Aktif

Aktif

Pasif

Pasif

Fleksi paha

Dextra .............

Sinistra .............

Dextra .............

Sinistra .............

Ekstensi paha

... .............

... .............

... .............

... .............

Endorotasi paha

... .............

... .............

... .............

... .............

Adduksi paha

... .............

... .............

... .............

... .............

Abduksi paha

... .............

... .............

... .............

... .............

Fleksi lutut

... .............

... .............

... .............

... .............

Ekstensi lutut

... .............

... .............

... .............

... .............

Dorsofleksi pergelangan kaki

... .............

... .............

... .............

... .............

Plantar fleksi pergelangan kaki

... .............

... .............

... .............

... .............

Inversi kaki

... .............

... .............

... .............

... .............

Eversi kaki

... .............

... .............

... .............

... .............

...

...

...

... Test Provokasi Stres test Drawer’s test Test tunel pada sendi lutut Test homan Test lain – lain PEMERIKSAA N FISIK

RUA NG

Kanan ................ ................ ................ ................ ................

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

NO. MED. REK

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

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

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

NAM A

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

Umur / JK

: ............ .... thn / L/P

III. Pemeriksaan - Pemeriksaan lainnya Pemeriksaan refleks – refleks primitive pada anak – anak dengan gangguan SSP Righting reaction

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

Reaksi keseimbangan

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

Pemeriksaan lainnya

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

Bowel test / Bladder test -

Sensorik perianal

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

-

Motorik sphinter ani

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

-

eksternus BCR ( Bulbocapernosis

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

Refleks ) Fungsi luhur -

........

Afasia

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

Apraksia

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

Agrafia

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

Alexia

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

IV. PEMERIKSAAN PENUNJANG A. RADIOLOGIS

:

....................................................................................................................... .............................. ....................................................................................................................... .............................. B. LABORATORIUM

:

....................................................................................................................... .............................. ....................................................................................................................... ..............................

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

C. LAIN – LAIN CT - Scan /

:

MRI ....................................................................................................................... .............................. ....................................................................................................................... ..............................

RESUME

RUA NG

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

NO. MED. REK

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

NAM A

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

Umur / JK

: ............ .... thn / L/P

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

V. RESUME .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. ..................................................................................................................................

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. ................................. .................................................................................................................................. .................................

EVALUASI / DIAGNOSIS

VI.

EVALUASI

RUA NG

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

NO. MED. REK

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

NAM A

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

Umur / JK

: ............ .... thn / L/P

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

N O 1

2

3

Level ICF

Kondisi saat ini

Sasaran

Struktur dan fungsi

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tubuh

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Aktivitas

Partisipasi

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK .....................................

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

PEMERIKSAA N FISIK

RUA NG

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

NO. MED. REK

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

NAM A

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

Umur / JK

: ............ .... thn / L/P

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

VII. PROGRAM REHABILITASI MEDIK Fisioterapi Terapi panas : ..................................................................................... ...................... ..................................................................................... ...................... Terapi dingin

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

Stimulasi listrik

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

Terapi latihan ..................................................................................... ..................... ..................................................................................... ..................... Okupasi Terapi : ROM exercise

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

ADL exercise Ortotik Prostetik Ortotic

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

Prostetic

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

Alat bantu ambulasi Terapi wicara Afasia

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

Dysartria

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

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

Dysfagia

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

Social Medik

..................................................................................... ......................

Edukasi

..................................................................................... ......................

PEMERIKSAA N FISIK

RUA NG

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

NO. MED. REK

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

NAM A

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

Umur / JK

: ............ .... thn / L/P

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

VIII. TERAPI MEDIKAMENTOSA ................................................................................................................................... ................................. ................................................................................................................................... ................................. ................................................................................................................................... ................................. ................................................................................................................................... ................................. ................................................................................................................................... ................................. ................................................................................................................................... ................................. ................................................................................................................................... ................................. ................................................................................................................................... ................................. ................................................................................................................................... ................................. ................................................................................................................................... ................................. ................................................................................................................................... ................................. ................................................................................................................................... ................................. IX. PROGNOSA Medik

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

................

Fungsional

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

FK. UNSRI PALEMBANG

RM. R BAGIAN REHABILITASI MEDIK

................ X. FOLLOW UP Tanggal

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

............... Keluhan

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

.............. Pemeriksaan umum

: ......................................................................................................... Keadaan

khusus

: ......................................................................................................... Fungsional

:

Barthel index

:

FIM index

:

Katz index

:

Status Ujian Rehab.medik

Short Description

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