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R 1
BAGIAN REHABILITASI MEDIK
I. ANAMNESIS
1. KELUHAN UTAMA
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5. RIWAYAT PEKERJAAN
6. RIWAYAT SOSIAL EKONOMI
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FK UNSRI PALEMBANG RM.R 2
BAGIAN REHABILITASI MEDIK
A. Pemeriksaan Umum
Kesadaran :G C S :
Nama : Umur : L / P
C. Kepala
Bentuk : ............................................................................................................
Ukuran : ............................................................................................................
Posisi :.............................................................................................................
- Mata :.............................................................................................................
- Hidung :.............................................................................................................
- Telinga :............................................................................................................
- Mulut : ............................................................................................................
- Wajah : simetris / asimetris gerakan abnormal :
FK UNSRI PALEMBANG RM.R 4
BAGIAN REHABILITASI MEDIK
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 Valsalva :.
Distraksi test : Test Nafziger :.
E. Thorak
Bentuk :.
Pemeriksaan Ekspansi Thoraks : Ekspirasi maksimum .......Cm Inspirasi Maksimum ..........cm
Paru- paru
- Inspeksi : ..
- Palpasi :..
- Perkusi : .
- Auskultasi : ..
Jantung
- Inspeksi : ..
- Palpasi : .
- Perkusi : ..
- Auskultasi : ..
F. Abdomen
- Inspeksi : .
- Palpasi : .
- Perkusi : .
- Auskultasi :
Nama : Umur : 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 lumbosakral
- Ante /retro fleksi (95/35) :./..
- Laterofleksi (D/S) (40/40) :/...
- Rotasi (D/S) (35/35) :./.
Test provokasi
- Valsava test :Tes Laseque :./.Test : Baragard dan Sicard :./.
- Niffziger test : Test SLR :./. Test: OConnell :./
- FNST :../.Test Patrick :. /.Test Kontra Patrick :/
- Test Gaenslen :../.Test Thomas:. /. Test Obers :/
- Nachalas knee flexion test :../.. Mc.Bride sitting test :./..
- Yeomans hyprextension :../.. Mc.Bridge toe to mouth sitting test ;./..
- Test Schober :
H. Anggota Gerak Atas
Inspeksi kanan kiri
- Deformitas : .
- Edema :
- Tremor :
- Nodus heberden :
Ruang : No.Rek.Med :
Palpasi
FK UNSRI PALEMBANG RM.R 6
BAGIAN REHABILITASI MEDIK
PEMERIKSAAN FISIK /
NEUROLOGI Nama : Umur : L / P
Neurologi
Motorik Dextra Sinistra
Gerakan .............................. ........................................
Kekuatan .............................. ........................................
Abduksi lengan .............................. ........................................
Fleksi siku ............................... ........................................
Ekstensi siku ............................... ........................................
Ekstensi Wrist ............................... .........................................
Fleksi jari- jari tangan ............................... ........................................
Abduksi jari tangan ............................... ........................................
Tonus ............................... .........................................
Tropi ............................... ........................................
Refleks Fisiologis
Refleks tendon biseps ............................... .......................................
Refleks tendon triseps .............................. ......................................
Refleks Patologis
Hoffman ............................... .......................................
Tromner .............................. ........................................
Sensorik
Protopatik :.....................................................................................................................
Proprioseptik :....................................................................................................................
Vegetatif :....................................................................................................................
Neurologi
Vegetatif : .
Fleksi paha . ..
Ekstensi paha . ..
Endorotasi paha . ..
Adduksi paha . ..
Abduksi paha . ..
Fleksi lutut . ..
Ekstensi lutut . ..
Dorsofleksi pergelangan kaki . .
Plantar fleksi pergelangan kaki . .
Inversi kaki . .
Eversi kaki . .
Righting reaction :
Reaksi keseimbangan :
Pemeriksaan lainnya :
V. RESUME
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FK UNSRI PALEMBANG RM.R 12
BAGIAN REHABILITASI MEDIK
VI. EVALUASI
3 Partisipasi .. ..
.. ..
. .
DIAGNOSIS KLINIS
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FK UNSRI PALEMBANG RM.R 13
BAGIAN REHABILITASI MEDIK
Ortotik prostetik
Ortotic :................................................................................................
Prostetic : ...............................................................................................
Alat bantu ambulasi :................................................................................................
Terapi wicara
Afasia : ................................................................................................
Dysartria :.................................................................................................
Dysfagia :.................................................................................................
Edukasi :..................................................................................................
..................................................................................................
FK UNSRI PALEMBANG RM.R 14
BAGIAN REHABILITASI MEDIK
IX . PROGNOSA
Mmmm - Medik :
- Fungsional :.
X . FOLLOW UP
Tanggal :.
Keluhan : .
Pemeriksaan Umum : .
Keadaan khusus : .
FIM Index :
Katz index :