STATUS UJIAN

KEPANITERAAN KLINIK SENIOR

ILMU PENYAKIT SARAF (NEUROLOGI)

NAMA : ...............................................................

NIM : ...............................................................

SEMESTER : ...............................................................

TANGGAL : ...............................................................

PENGUJI : ...............................................................

BAGIAN / DEPARTEMEN ILMU PENYAKIT SARAF (NEUROLOGI)

FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA / RSMH

PALEMBANG
 STATUS PENDERITA NEUROLOGI

IDENTIFIKASI
Nama : .................................................................................
Umur : .................................................................................
Jenis Kelamin : .................................................................................
Alamat : .................................................................................
Agama : .................................................................................
MRS Tanggal : .................................................................................

ANAMNESA (Auto / Allo Anamnesa)

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PEMERIKSAAN
STATUS PRESENS
Status Internus
Kesadaran : .................................... GCS = ........... (E: …., M: ....., V: .......)
Gizi : ....................................
Suhu Badan : .................................... Jantung : ....................................
Nadi : .................................... Paru-paru : ....................................
Pernapasan : .................................... Hepar : ....................................
Tekanan Darah : .................................... Lien : ....................................
Berat Badan : .................................... Anggota Gerak: ....................................
Tinggi Badan : .................................... Genitalia : ....................................

Status Psikiatrikus
Sikap : .................................... Ekspresi Muka: ....................................
Perhatian : .................................... Kontak Psikik: ....................................

Status Neurologikus
KEPALA
Bentuk : .................................... Deformitas : ....................................
Ukuran : .................................... Fraktur : ....................................
Simetris : .................................... Nyeri fraktur : ....................................
Hematom : .................................... Pembuluh darah: ....................................
Tumor : .................................... Pulsasi : ...................................

LEHER
Sikap : .................................... Deformitas : ....................................
Torticolis : .................................... Tumor : ....................................
Kaku kuduk : .................................... Pembuluh darah : ....................................

SYARAF-SYARAF OTAK
N. Olfaktorius Kanan Kiri
Penciuman .................................... ....................................
Anosmia .................................... ....................................
Hyposmia .................................... ....................................

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 Kanan Kiri

Parosmia .................................... ....................................

N.Opticus
Visus .................................... ....................................
Campus visi V.O.D V.O.S

- Anopsia .................................... ....................................

- Hemianopsia .................................... ....................................
Fundus Oculi
- Papil edema .................................... ....................................
- Papil atrofi .................................... ....................................
- Perdarahan retina .................................... ....................................

Nn. Occulomotorius, Trochlearis dan Abducens

Kanan Kiri
Diplopia .................................... ....................................
Celah mata .................................... ....................................
Ptosis .................................... ....................................
Sikap bola mata
- Strabismus .................................... ....................................
- Exophtalmus .................................... ....................................
- Enophtalmus .................................... ....................................
- Deviation conjugae .................................... ....................................
Gerakan bola mata .................................... ....................................
Pupil
- Bentuknya .................................... ....................................
- Besanya .................................... ....................................
- Isokori/anisokor .................................... ....................................
- Midriasis/miosis .................................... ....................................
- Refleks cahaya

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 Kanan Kiri
- Langsung .................................... ....................................
- Konsensuil .................................... ....................................
- Akomodasi .................................... ....................................
- Argyl Robertson .................................... ....................................

N.Trigeminus
Kanan Kiri
Motorik
- Menggigit .................................... ....................................
- Trismus .................................... ....................................
- Refleks kornea .................................... ....................................
Sensorik
- Dahi .................................... ....................................
- Pipi .................................... ....................................
- Dagu .................................... ....................................

N.Facialis Kanan Kiri

Motorik
Mengerutkan dahi .................................... ....................................
Menutup mata .................................... ....................................
Menunjukkan gigi .................................... ....................................
Lipatan nasolabialis .................................... ....................................
Bentuk Muka
- Istirahat .................................... ....................................
- Berbicara/bersiul .................................... ....................................
Sensorik
2/3 depan lidah .................................... ....................................
Otonom
- Salivasi .................................... ....................................
- Lakrimasi .................................... ....................................
- Chovstek’s sign .................................... ....................................

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N. Statoacusticus
N. Cochlearis Kanan Kiri
Suara bisikan .................................... ....................................
Detik arloji .................................... ....................................
Tes Weber .................................... ....................................
Tes Rinne .................................... ....................................

N. Vestibularis
Nistagmus .................................... ....................................
Vertigo .................................... ....................................

N. Glossopharingeus dan N. Vagus

Arcus pharingeus ....................................
Uvula ....................................
Gangguan menelan ....................................
Suara serak/sengau ....................................
Denyut jantung ....................................
Refleks
- Muntah ....................................
- Batuk ....................................
- Okulokardiak ....................................
- Sinus karotikus ....................................
Sensorik
- 1/3 belakang lidah ....................................

N. Accessorius
Mengangkat bahu ....................................
Memutar kepala ....................................

N. Hypoglossus
Mengulur lidah ....................................
Fasikulasi ....................................
Atrofi papil ....................................
Disartria ....................................

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MOTORIK
LENGAN Kanan Kiri
Gerakan .................................... ....................................
Kekuatan .................................... ....................................
Tonus .................................... ....................................
Refleks fisiologis .................................... ....................................
Refleks patologis
- Hoffman Trommer ....................................
- Leri ....................................
- Meyer ....................................

TUNGKAI Kanan Kiri

Gerakan .................................... ....................................
Kekuatan .................................... ....................................
Tonus .................................... ....................................
Klonus
- Paha .................................... ....................................
- Kaki .................................... ....................................
Refleks fisiologis
- KPR .................................... ....................................
- APR .................................... ....................................
Refleks patologis
- Babinsky .................................... ....................................
- Chaddock .................................... ....................................
- Oppenheim .................................... ....................................
- Gordon .................................... ....................................
- Schaeffer .................................... ....................................
- Rossolimo .................................... ....................................
- Mendel Bechterew .................................... ....................................
Refleks kulit perut
- Atas ....................................
- Tengah ....................................
- Bawah ....................................
Refleks cremaster ....................................

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SENSORIK
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GAMBAR

FUNGSI VEGETATIF
Miksi : ....................................
Defekasi : ....................................

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KOLUMNA VERTEBRALIS
Kyphosis : ....................................
Lordosis : ....................................
Gibbus : ....................................
Deformitas : ....................................
Tumor : ....................................
Meningocele : ....................................
Hematoma : ....................................
Nyeri ketok : ....................................

GEJALA RANGSANG MENINGEAL

Kanan Kiri
Kaku kuduk ....................................
Kernig .................................... ....................................
Lasseque .................................... ....................................
Brudzinsky
- Neck ....................................
- Cheek ....................................
- Symphisis ....................................
- Leg I .................................... ....................................
- Leg II .................................... ....................................

GAIT DAN KESEIMBANGAN

Gait Keseimbangan dan Koordinasi
Ataxia : .................................... Romberg : ....................................
Hemiplegic : .................................... Dysmetri : ....................................
Scissor : .................................... - jari-jari : ....................................
Propulsion : .................................... - jari hidung : ....................................
Histeric : .................................... - tumit-tumit : ....................................
Limping : .................................... Rebound phenomen : ....................................
Steppage : .................................... Dysdiadochokinesis : ....................................
Astasia-Abasia: .................................... Trunk Ataxia : ....................................
Limb Ataxia : ....................................

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GERAKAN ABNORMAL
Tremor : ........................................................................
Chorea : ........................................................................
Athetosis : ........................................................................
Ballismus : ........................................................................
Dystoni : ........................................................................
Myocloni : ........................................................................

FUNGSI LUHUR
Afasia motorik : ........................................................................
Afasia sensorik : ........................................................................
Apraksia : ........................................................................
Agrafia : ........................................................................
Alexia : ........................................................................
Afasia nominal : ........................................................................

LABORATORIUM
DARAH
Hb : .................................... Kolesterol HDL : ....................................
Eritrosit : .................................... Kolesterol LDL : ....................................
Leukosit : .................................... Trigliseride : ....................................
Trombosit : .................................... Total Lipid : ....................................
Diff count : .................................... Uric Acid : ....................................
Hematokrit : .................................... Ureum : ....................................
BSS : .................................... Kretinin : ....................................
BSN/BSPP : .................................... WR/KAHN/VRDL : ....................................

URINE
Warna : .................................... Sedimen :
Reaksi : .................................... - Eritrosit : ....................................
Protein : .................................... - Leukosit : ....................................
Reduksi : .................................... - Thorak : ....................................
Urobilin : .................................... - Sel Epitel : ....................................
Bilirubin : .................................... - Bakteri : ..................................

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FAECES
Konsistensi : .................................... Histolitika : ....................................
Lendir : .................................... Eritrosit : ....................................
Darah : .................................... Leukosit : ....................................
Amuba Coli : .................................... Telur cacing : ....................................

LIQUOR CEREBROSPINALIS

Warna : .................................... Protein : ....................................

Kejernihan : .................................... Glukosa : ....................................
Tekanan : .................................... Nacl : ....................................
Sel : .................................... Queckensted : ....................................
Nonne : .................................... Celloidal : ....................................
Pandy : .................................... Culture : ....................................

PEMERIKSAAN KHUSUS
Rontgen foto cranium : ..............................................................................................................
Rontgen foto thoraks : ..............................................................................................................
Rontgen foto vertebralis : ..............................................................................................................
Electroencephalografi : ..............................................................................................................
Electroneuromyografi : ..............................................................................................................
Electrocardiografi : ..............................................................................................................
Arteriografi : ..............................................................................................................
Pneumografi : ..............................................................................................................
CT-Scan : ..............................................................................................................
Lain-lain : ..............................................................................................................

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RINGKASAN
ANAMNESA
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PEMERIKSAAN
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DIAGNOSA
DIAGNOSA KLINIK : ..................................................................................................
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DIAGNOSA TOPIK : ..................................................................................................
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DIAGNOSA ETIOLOGI : ..................................................................................................
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PENGOBATAN : ..................................................................................................
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PROGNOSA : ..................................................................................................
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