STATUS PASIEN

CEREBRAL PALSY

I. Identity
II. Anamnesis
- Chief complain & history of present illness (riwayat tumbuh kembang sebelum dan
setelah sakit)
- Riwayat antenatal, natal, postnatal (mencari factor resiko CP)
- Milestone
III. Physical examination

a. Status General
 Lingkar kepala, status gizi, posture
b. Status Muskuloskeletal
 ROM
 MMT
o Neck control : good/poor
o Trunk control : good/poor
o Upper Ext : F/WF/NF
o Lower Ext : F/WF/NF
c. DDST (gross motor, fine motor, language, personal social)
d. Functional examination :
 Sitting balance : static & dynamic
 Standing balance : static & dynamic
 Transfer :
o Lying to sitting
o Sitting to standing
 Hand function (bisa dengan MACS)
  Pola gait :
o Hemiplegic gait :
o Scissoring : cross over leg saat berjalan
o Jump gait : hip flx, knee flx, ankle planarflx saat stance phase
o Crouch gait : knee flx, ankle hyperdorsiflx saat stance phase
o Stiffed knee gait : decrease knee flx saat swing phase
o Trunk lurch : increase side-to-side trunk movement saat berjalan krn
deficiency balance
 Level GFMCS : (tabel di bawah pada usia 6-12 th)

e. Status Neurology :
 Cranial nerve :
 Tonus / spasticity :
 DTR :
 Pathological Ref :
 CNS maturation :
o Level spinal : flexor withdrawal, extensor trust, cross extension
o Level brainstem : ATNR, STNR
o Level midbrain : body righting on the body, labyrinthine righting acting on the
head, optical righting
o Level cortical : hopping, sitting, kneeling
 Assesment sensory integration : impressed (hyper/hyposensitive/sensory seeking)
o Touch
o Taste
o Hearing
o Visual
o Smell
o Proprioceptive
o Vestibular
f. Levine Criteria (bukan kriteria diagnosis CP lagi) :
 Posture
 Oral drooling
 Strabismus
 Tonus
 Evolution CNS
 Reflexes : physiological & pathological
f. Other examination :
 Cognitive
 Eye contact
 Communication ability (bisa dengan CFCS) :
o Receptive : kemampuan mendengar perintah atau sumber suara
o Expressive : kemampuan berbicara
 Deformities or contracture
o Common site contracture (AGA : pronator, wrist & fingers flx ; AGB : hip flx,
knee, ankle plantarflx)
o Scoliosis, pelvic obliquity, leg length discrepancy
o Examination for contracture hip flx :
 Thomas test
 Ely’s test
o Examination for contracture hip adduction
o Ortolani test (for hip dislocation krn dominasi hip add & int rot  tendensi
hip dislocation)
o Examination for torsional abnormality in lower extremity :
 Femoral anteversion
 Femoral retroversion
 Tibial torsion (TFA/Thigh foot angle) : normal 0-300 ext rot
 FPA/Foot progression angle : normal 0-300 ext rot
 Feeding ability
Prognosis Ambulasi (Molnar & CP Help) :
 Berdasarkan tipe CP
o Hampir 100% hemiplegia bisa ambulasi
o 85% diplegia bisa ambulasi
o 0-72% quadriplegia bisa ambulasi
 Saat usia 2 thn :
o Sdh bisa duduk  prognosis ambulasi baik
o Reflex primitive (+) & postural reaction (-)  prognosis ambulasi buruk
o GFMCS level I, II, III  prognosis ambulasi baik
o GFMCS level IV, V  prognosis ambulasi buruk
 Severe intelectual impairment  prognosis ambulasi buruk
 Saat usia 5-7 thn ada severe developmental delay & belum bisa berdiri  tidak bisa berjalan