PEMERIKSAAN

FISIK DASAR
KELAINAN ORTHOPAEDI
Dr. Hari Tjahyono, SpOT

DATA

History

Physical examination

Photo

Laboratorium

HISTORY
Keluhan utama
- Pain : - Nyeri
- Anestesi
- Parestesi
- Penurunan fungsi
- Physical Appearance
- Deformity
- Atrophy
- Scoliosis
- Relevant past history : penyakit sebelumnya
- Penyakit penyerta : Jantung, ren, diabetus melitus,
respiratory, psychic
- Family history

Physical examination

Body build : Wajah, gait (walking),

duduk, tidur
Looking (inspection)
Feeling (palpation)
Moving (Assessment of joint motion)
Listening (auscultation)
Special physical test
Neurological examination

LOOK (INSPECTION)

Warna kulit : merah, cyanosis,

pigmentation, pucat, luka

Swelling

Limb shortening / atrophy

Gait

FEEL (PALPATION)

Hangat
Dingin
Size (ukuran)
Dislocation
Crepitus

MOVE (ASSESSMENT OF JOINT

MOTION)

Passive movement

Joint instability

Range of motion

LISTENING (AUSCULTATION)

Crepitus

Snapping tendon

Murmur arteriorvenous fistula

PHYSICAL TEST
Flexion deformity : Thomas test
Trendelenburg test
Instability: - Ortholani
- Laseque Test
- Mc Murray Test
Neurological examination :
- Muscle : Weakness
Spasticity
- Sensation
- In coordination
- Reflex tendon

RADIOGRAPHIC EXAMINATION

Identitas pasien
Tulang :
AP Lateral melampaui kedua sendi
Densitas naik : sclerosis
Rarefaction
General density, local density
Hubungan tulang : dislocation, subluxasi
Break in bone : fracture line (transfer, Oblique,
segmental, comminutive, rotasi, cumcontractionum,
cumdistractionum, angulasi)
General / local countour : Deformity, Irregularity

RADIOGRAPHIC EXAMINATION

Sendi
Articular cartilage : Space sendi
Soft tissue
Comparation of a limb
Special photo
: contras / medium
Arthrogram
: dalam sendi
Myelogram
: sub arachnoid
Sinosgram
: dalam sinus
CT Scan
MRI
Bone Survey

LABORATORIUM EXAMINATION

Darah lengkap
Leukocyte, LED, Thrombocyte, HB
Serum : Mantoux (TBC)
Rose test (Rheumathoid desease)
Urine : - Albumin, gula, cell, kristal
- Cultur
Cerebro spinal fluid : Protein, cell, Cultur
Abnormal fluids : Effusion, Exudates
Gross, smear, cultur,
resistance antibiotic

BODY TISSUE

Gross
Biopsi

Semua data dikorelasikan untuk

diagnose dan diferensial diagnose