D SEEMING Student Record pi ms tapieist | QUPH LEMBAR KASUS STATUS NEUROLOGI / NEUROLOGY CASE SHEET Status Lengkap / Complete Status Identitas Pasien / Patient Identity Paninron Ox, Wiel Pasion 7 Patio Ta Kelamin / Sex Tanggal Lotir/D 0B : Status Perkawinan! Maral Status: Agama Religion | Educational Status Adéroes Keluargs Yong Bisa Dihubungi/ Family Coniact Number Pekerjaan / Occupation | Masuk RS / Date of Admission | Temerksaan Date of Examintin:/ am Tne 1 Autoanamnesis C Alloanammness dri © Autosnsmnesis (1 ANloanamnesis fo Tanggal Pulang /Date of Discharge: Wh Jam /Time : (alloanamnesis/autoanamnesis) KELUHAN UTAMA/ CHIEF COMPLAIN ;™* 0. deen Eeluhoo 3 tuo Frnag . RIWAYAT PENYAKIT. SEKARANG / Present Iliness ‘History: Pe datongy ogy Fetuhan —erdeulan treaty tamba She 4 tan toy | Wr eras reorgeot, — qemton mergady otw. Jas lagen Dp Feu , untae MOEN | Cerdoel ques Suit- Dak-Yos dic bargin 2, Boden’ Die emin gu, Dan megaman exon eu’ egotar Sens sont pe Felony Mam x Bug? mere Ma WapiE - Songun’ | bese Lear, ty Fults merigat . BAB - BAC @s RIWAYAT PENYAKIT. DAHULU / Past IIiness History brpalan ery tga be woppateag Dod nO mo traua® ‘anya untuk kebutuhan pendidikan For educational purpose only aogi O ‘smi 403.90% Scanned with CamScannerr ‘ ; ILTY OF SIGE Niecss MEDICINE | ? Student Record RIWAYAT KELUARGA / Family History: Flo odo Yq purya agate cepupe. RIWAYAT SOSIALKEBIASAAN/POLA HIDUP (Social History / Life style ): © PEMERIKSAAN FISIK / PHYSICAL EXAMINATION STATUS GENERALIS - Keadsan umum/ General Appearance: “WEBR..T6P. Kesadsran/ Consciousness: CVA(EAUUAMG) b. Tekanan darah/ Blood Pressure: (20/0 Pemapasan/ Breath Nadif Heart ate : BO Suhu/ Temperature Kepab / Head Mormocepvaty . _ Mata / Eve at: a 7 ‘THT /ENT Sekret— Leber / Neck pembesaran Age - Thoax/ Thorax... peryemeacgan tae? Bwenis . Panu / Lung ver Te wee wh TH Jantung/ Cor fae, me 9° Abdomen {Abdomen WO nI@Q « -Pungging/ Back’ © ‘tia Bates / Ex Fane ‘at ‘Hanya untuk kebutuhan pendigikan | Fr educational purpose only ‘STH 1403.10 Scanned with CamScannerA r Bie s esac gbicise | @UPH nena cee enannnann ge Student Record STATUS NEUROLOGIS / NEUROLOGICAL STATUS : Ges. Eyus ‘Tanda rangsang meningeal/ Meningeal sign Kakukuduk Neck stifiness Tanda Laseq / Laseque sign Tanda Kernig / Kern sign © Bruczinki / Brudzinsh sign Bradzinski Il / Brudzinsqi Il sign SarafKranialis / Cranial nerve Kanan Kiri ‘Nervus 1 : gangguan menghidu /Olfactory Disorders: etoe stature, Nerwus I Visus / Vision Kampus/lapang pandang (konfrontasi test) / Visual field: @ Asiatukan Warna / Colour Fundus / Fundus ‘Nervus Il, IV, VI Sikap bola mata offer CebhPalpebra = @) Pupil : ukuran, bentuk (Size, shape) 3MM/am™ ular, Foor - Reflex cahaya langsung/ Direct light reflex ~ y 4 45 Reflex cahaya tidak langsung / Indirect light reflex Reflex konvergensi / Convergency reflex, Nistagmus /Nystagmus —7— Pergerakan bola mata / Eye movement he Nervus V Motorik / Motoric Inspeksi/Inspection wom. Palpasi/ Palpation\ Wocmerouy © Membuka mulut / Open mouth Gerakan rabang/Jaw movement © Sensorik / Sensoric " Sensibilitas VI /V1 sensibility . Sensibilitas V2 /V2 sensibility ye oT , Sensibilitas V3 /V3 sensibility Reflex kormea /Comealrefler 174. “enya untuk kebutuhan pendiikan For educational purpose only STH 1403.101 Scanned with CamScannermepieise| G OUP | . MEDICINE 2 ofise Student Record me ines DOIN IA AIDOLONITA AUTATE ‘Nervus VII SQSTRTZ UM OOSONIS Sikap mulutistrahat / Resting mouth movement i ce opaeiee.) Angkatalis, kerut dahi, Yen a datos. futup mata dengan kuat / A sh hess wef ‘Kembung pipi Menyeringai Rasa kecap 2/3 anterior fi Nervus VIL vic Wideustanél Nervus cochlearis ' Suara bisikan / Sung gestanjari vse J Orel Asano ota Rinne Weber @ euestucar ae , ‘Schwabach. Voit \ (eat iemmoiiaod) gusbang yauql arpa Nervus vestibularis ; ‘Nistagmus Q : Berdiri dengan satu kaki: Mata tertutup (Stand with I feet : Close eye) \ii Mata terbuka (open eye) 12 iss Berdiridengan2 kaki: Mata tertutup a L ‘Mata terbuka’ agyed dutasd Berjakin tandem = —> gage Laibeti\ 2 Fukuda stepping test” metambabs\ |g Past pointingtest —> @® cnarvew N.IXX Arkus faring / Phaimx drch- Moric Uvuh Atrorgat, Disfoni/ Dysphony . Disfagi/Dysphagy 3 worisegpol tmtaq et Reflex faring / Pharynx reflex = —> @ 7 N.XI d iesuniecan Sternocleidomastoid YO aparurer- ‘Trapezius : N.XIL t - ‘Sikap lidah dalam mulut 7 Deviasi / Deviation Auofi / Atrophy L Fasikubsi / Fasciculation Tremor / Tremor ‘ votiihnge navuiueHanya wnt kebutuhan pendldikan | For educational purpose only STH 1403:1071 Scanned with CamScannerSEENIEes Student Record Menjuturkan tidah ¥ fe Kekuatan tah MOTORIK / MOTORIC Extremitas Atas / Upper Extremity Inspeksi/ Inspection » Woeetotrog, Aurofi / Atrophy Us Fasikulasi / Fasciculation eo Palpasi : tonus (Palpation : Tone). wormermug Kekuatan / Power Sendi bahu/ Shoulder Joint Biceps ‘Triceps Pergelangan tangan/ Hand movement Extensi Jari / Finger extension Menggenggam/ Grasp Gerakai Extremitas bawah / Lower Extremity Inspeksi / Inspection Atrofi/ Atrophy () Fasikulsi / Fasciculation (> Palpasi: tonus (Palpation Tone) woeserna , Kekuatan / Power luteus Hip flexor + Quadriceps hamstring Ankle dorsi flexi Gastrocnemius Gerakan involunter/ Involunter Movement » (2. Refleks fisiologis / Physiologic Reflex se Biceps, Triceps al KPR te APR Refleks patologis / Patologic Reflex Babinski Chadock) * fs . Oppenheim) — Gordon /olunter | Involiinter Movement °@) > wigpieist | @QUPH ge | Ss vy) | @- RESUME: DIAGNOSIS / DIAGNOSE 4 ae. Porrerent wgadlly Kins ‘Cinie: waajeeneia, Tag em, eebtte ORMeueas Tops Topic: Gyarersia wgra eaperes Evobgi Etiology: Regengeym neu) iB Patologis Parology : © aopaunin, Ley teeter . 5B ay caym Feuihan SerOelen O66 Th ern ate Wem SORE «eral Det eat a keny EY rudk aggretan te tah 7 bein, aw fen Redn PF ALIEN MIG Trem (SAU metomnbat 2 faco PF evvlonik, fowt Got edge taka. quent © Hanya untuk kebutuhan pendidikan |For educatione! purpose only STH 1403.40 Scanned with CamScannerteas noaS RA ASNNTEAD RELY FEY ULLaa eae © SENS Student Record, DIAGNOSIS KERJA / WORKING DIAGNOSE Ragemgon 2- DIAGNOSIS BANDING | DIFFERENTIAL DIAGNOSE Romvpuim - WF ged Denerha- PROGNOSIS | PROGNOSE Ad vitam 2 Alera. ad konare Ad functionam : elubtaed matem » Ad samionam > yor ef wre ‘SARAN PEMERIKSAAN PENUNJANG / CT head ry Aeed - SARAN TERAPI/ THERAPY SUGESSION Lwvodopa 3X5 9 tpebegtpergde ° UD - feavigede (FO03% [Nama dan td mahasiswa/ Stilent’sname and signature © frasteria To) Booteapr tncixe | QUPH = helopa W009, bagalon 9 Aaeinbagan Preceptor/Precepior Hanya unt kebutuhan pendisian For educations! purpose only srH403 104 Scanned with CamScanner