" SIEERISTESTE ngsziee | @UPH Student Record LEMBAR KASUS STATUS NEUROLOGI / NEUROLOGY CASE SHEET Status Lengkap / Complete Status Identitas Pasien / Patient Identity Porter: Vr Tnisial Pasien / Patient Initial RSH SYAHIRUL FLUBIS Kelemin/ Sex 2 Soe: Mle / Ph: 081310617000 ee [See Salus Perkawinaw Marto! Status amin Agama Religion Pencidkan/Eaucationa Status ‘Alamat / Addrees Keluarga Yang Bisa Dihubungi/ Family Contact Number Pekerjaan / Occupation Tanggal Masuk RS / Date of Admis : Flere Jam/Time : ‘Tanggal Pemeriksaan / Date of Examination :'4j2/,, Jam/Time O Autoanamnesis 0 Alloanamnesis dari. 0 Autoanamnesis (i Alloanamnesis fro ‘Tanggal Pulang /Date of Discharge :Yn{w- Jam/Time: ANAMNESIS (alloanamnesis/autoanamnesis) KELUHAN UTAMA/ CHIEF compLain : ¥ © « foe ie tas Soe Leggy Smeg - RIWAVAT PENYAKIT SEKARANG / Present Illness History: mK wa FOeY chi ign fur spe 4 my CM. faru airasatan mucoid Cort prodargan tagan, dapi lama* Fmpot 4 fagen 9 Sr) och tide digeaeran. Te apa “sclutan Fe rte tue Baek Px Dua Sees Lupe abu Wg auar bexomunikaed dm Renuayge rea Palit Adar. Me lS Brewin muni bet Zee semtet Yernens ma bm Err panctooe RIWAYAT PENYAKIT DAHULU / Past Illness History : rdicgwesq — portintoy Stan yl itt O, OME. Hanya untuk kebutuhan pendidtkan For eduestional purpase only. ‘STH 1403.1071 trauma @ iS Scanned with CamScanner«| QUPH acu SEN Gg MED Student Record RIWANAV2IMRIUARGA / Family History: © RIWAYAT SOSIALIKEBIASAAN/POLA HIDUP (Social History /Life style) | | PEMERIKSAAN FISIK / PHYSICAL EXAMINATION ~ STATUS GENERALIS - 1 Keadaan umm / General Appearance: TSP» Kesadaran/ Consciousness : Gy Us7M6_ | Tekanan darah / Blood Pressure : 9 (30 Pemapasan/ Breath : 16. Nadi Heart ate 0 © Sahu / Temperature 2 36.6, Kepala / Head woemucepvade. | Mata / Eye aot. 8 T- ‘THT /ENT Serer > Leher / Neck pmbowran > © Thorax / Thorax Guuetpis pergembangan oa Paru / Lung yerttt, ra t- 1 Wh cs Jantung/ Cor Sh e7.'S, 96 Abdomen /Abdomen quip, IG - Punggung/ Back — atormubay, GD Extemias /Extremity E80 Baga , cat er clehe Hanya untuk kebutuhan pendicikan | For educational purpose only STH 1403.10/1 Scanned with CamScannerSERINE Student Record igpiense| @UPH s STATUS NEUROLOGIS / NEUROLOGICAL STATUS : Ses tn Gy UG Tanda rangsang meningeal/ Meningeal sign Kaku kuduk / Neck stiffness Tanda Laseq / Laseque sign duiagutan . Tanda Kerniq / Kernig sign @ Aras Brudzinskill/ Brudzinski I sign Brudzinski ll / Brudzinsgi II sign SarafKranialis / Cranial nerve Kanan Kiri ‘Nervus I : gangguan menghidu / Olfactory Disorders: @ Ajaracan ‘Nervus I: Visus / Vision ‘Kampus/lapang pandang (konfrontasi test)/ Visual field: @ eAiexter” « Warna / Colour Fundus / Fundus Nervus Ill, IV, VI Au ‘Sikap bola mata o60RO A Celh Palpebra_ 4S bp Pupil : ukuran, bentuk (Size, shape ) sin (nen, buat. Meopor- Reflex cahaya langsung/ Direct light reflex Reflex cahaya tidak langsung// Indirect light reflex Y ts t Reflex konvergensi/ Convergency refler Nistagmus /Aystagmus 7 Pergerakan bola mata / Eye. ‘movement —> > - News V Seuor mt Motorik / Motorie > Inspeksi/ Inspection S Palpasi/Palpation ~~ Membuka mulut / Qpen mouth Gerakan rahang / Jaw movement 4 apr diloura - Sensorik / Sensoric Sensibilitas V1 /V1 sensibility Sensibilitas V2 /2 sensibility He Sensibilitas V3 /V3 sensibility Reflex kornea / Corneal reflex 5 (@. datoeuran. ee ‘untuk Kabutuhan pendiikan ‘Hanya untuk kabutuhan pendlik ees Scanned with CamScannerStudent Record Nervws Vil Sikap smutut tirahat tap mta den Kenbungpipi gerae Menyeringai Ras keeap 28 anterior Hoh Ag cpateon Nervus VIIL Rinne Weber ‘Schwabach Nervus vestioulars, Nistagmus ordiri dengan satu kaki: Mata tertutup (Stand with 1 feet : Close eye’) Mata terbuka (open eye ) suit whl Beni dengan2 kaki: Mata trtiup gotta (Bekeren Mata terbuka Berjalan tandem vgn Fukuda stepping test A aan Wy q Past pointing test Cs ot N.IXX Arkus faring /Pharynx arch “Quatre + ri * west Uv gy tesad, Disfoni/ Disphony Disfagi/Dysphagy D> “syniyvatrn) Vie Reflex faring /Pharynx reflex —% Gp Aarne? N.XI . : aero salt Sternocleidomastoid y Trapezius NXil ad Sikap lidah dalam mulut \ : Deviasi/ Deviatiin — > Atvofi/Atrophy = CS Fasikulasi / Fasciculation CG ~ ‘Tremor/ Tremor CB} oda Fada gat Uda arpotuortar Honya untuk kebutuhan pendidikan |For educational purpose only ‘STH 1403.10 Scanned with CamScannerStudent Record. Menjulurkan fdah tRemor GO) + Kehumtan fds, “vcah acsieie | Q@UPH MOTORIK/ MOTORIC Extremitas Atas / Upper Extremity Inspeksi laspection Atrofi/ Atrophy : Rosia, trewot Fasikulasi / Fasciculation © : Palpasi: tonus ( Palpation : Tone ) yoenorours ae Kekuatan / Power xh poe tr ‘Sendi bahu / Shoulder Joint eels Biceps Ye ad Triceps y My Pergclangan tangan/ Hand movement EytensiJari/ Finger extension Menggenggam/ Grasp : qenerte Gerakan involunter / Involunter Movement DOMa7] F “yasaeher Extremitas bawah / Lower Extremity Inspeksi/ Inspection Auofi/ Atrophy . Fasikulasi / Fasciewlation Palpasi :tonus ( Palpation : Tone ) oY 4 ve 8 Kekuatan / Power Giucews = : Hip flexor 2 eh 4 Quadriceps hamstring Pe ha. z ‘Ankle dorsiflexi aos ne Gastroenemis >, Geran volute! involunter Movement = eS’ 2 wml a “a Refleks fisiologis 1 Physiologie. Reflex, vt t i r Biceps - ‘Triceps 7 42 Py onis panos “ 7 KPR fae e APR mm » Refleks patologis / Patologic Reflex * Babinski haddock = Oppenbeim Gordon ‘a ‘Hanya untuk kebutuhan pendidikan! For educations! purpose only STH 1403.1074 Scanned with CamScannerSENSORIK SENSORIC me 4d ah KOORDIN ASI / COORDIANTION Tes TinjukeHidung ————— tremor) Tes TumiteL ut Dadindokoh nese JO OTONOM Misi \ Deki Geter > ® ciawen Sekresi keringat FUNGSI LUHUR : Giencas MMSE Pe dig gn tatu dt fm Her Soe 4 soy eg ote lt SCturth tn HIRI > Pusad, cgeratean . Ue PBa weretuleay Oa : gn sogetar Px tretx Panteinton 4 4hn yg tel Bf Renee ane lam @ tem Olak EMA — pardon). : ‘ ambaker erat Wagan amor, pgidity, & Le ue eon RESUME: —! oF. DIAGNOSIS / DIAGNOSE test ‘ Py ei Klinis /Clinie: @iggnoss, Memo, Generag wearnets, \upominne ¢ Ray oily Be, Tops /Topic: Syae . raqra- Etiologi / Etiology : enorak 6 - om neueon Oy - > Baw ws Patologis / Patology : . e@ depenerah > wpauun ete SD Mergeonrol FORE Hanya untuk kebutuhan pendidikan / For educational purpose only STH 1403.10/1 Scanned with CamScannerSEMNEeeg | FACULTY OF MEDICINE \¢ (@UPH Student Record DIAGNOSIS KERIA io, ‘ORKING DiAGNosE Pareingn Dy , witwn de (mutlpe Sypom Armas CMG | PIAGNOSIS BANDING / DIFFERENTIAL DIAGNOSE | | 1 | PROGNOSIS / PROGNOSE Ad vitam Ad farctionam 4 aueia od) mata Ad sation: SARAN PEMERIKSAAN PENUNJANG / mA sy W. exci MSA. SARAN TERAPI/ THERAPY SUGESSION 7 jean ma aa © wal andy ace ag Rend ox 66 ‘4 ¢ “Pebreniy prouictr(o hie tx % Woiox a tm. vicegs Cre Unit), ‘Nama dan tt Scanned with CamScanner