5 LI | EIRENE wesitive| @UPH | Student Record : LEMBAR KASUS STATUS NEUROLOGI/ NEUROLOGY CASE SHEET | Status Lengkap / Complete Status Identitas Pasien / Patient Identity Pyeiborrnes Gpebrore | Trisial Pasion / Patient Iniial Kelamin / Sex | Tanggal Lahir/ DOB | Status Perkawinar’ Marital Status ‘Agama / Religion Pendidikan | Educational Status ‘Alamat / Adarees Keluarga Yang Bisa Dihubungi/ Family Contact Number Pekerjean / Occupation “Tanggal Masuk RS /Date of Admission: /,/, Jam/Time : “Tainggal Pemeriksaan / Date of Examination :1#/2/,g, Jam /‘Time : 1 Autoanamnesis () Alloanamnesis dari Ci Autoanamnesis (| Alloanamnesis from... : Tanggal Pulang /Date of Discharge: Ynfio - Sam/Time : ANAMNESIS (alloanamnesis/auloanamnesis) KELUHAN UTAMA/ CHIEF COMPLAIN: *@# piggies eae’ + ban des. RIWAVAT PENVAKIT SEKARANG / Present Illness History: “ee FR og damn Fun nyeed p%Ios ak Abin MIRE. dyn grata nyont Yeo. oe mogeteiran ecto eosemuion franpal daw tent weary , On bigs hehe, oun MemiRe Aue Madu wie ¢ Baton & valle +VIIS- RIWAYAT PENYAKIT DAHULU / Past Iliness History + m © ar O Manye untuk kebutuhan pendidikan / For educational purpose only ‘smn 1403107 aeog O Scanned with CamScannerSEINISES ugsit| QUPH Student Record RIWAYNT, KELUARGA / Family History RPE Ausaigleoe RIWAYAT SOSIALKEBIASAAN/POLA HIDUP (Social History /Life sole): © | PEMERIKSAAN FISIK / PHYSICAL EXAMINATION STATUS GENERALIS Keadaan umum / General Appearance: TSR... Kesadaran/ Consciousness: tan Eavr(M6. TTekanan darah/ Blood Pressure : 20/80 . Pemapasan/ Breath > ip. Nadi/ Heart ate 1 2Y% ‘Suhu/ Temperature Bea Kepah / Head venaocephay Mata / Eye ott ste THT/ENT. seer © Leher / Neck prberien bye Thonx Thor pasemibayen docs HEME 05, | Para /Lung fe, oF 7 ° Jantung/ Cor Nir, wa go. 5 si Abdomen /Abdonei QUO, wi © ¥ apts Punggung/ Back —_defopunkar@) : Extremitas /Extremity Oval Quagat, G8 eedthe » 4 Hanya untuk kebutuhan penaiikan / For educational purpose only ‘STH 103.1071 Scanned with CamScannerfe “BREN esis MEDICINE | @UPH Student Record STATUS NEUROLOGIS / NEUROLOGICAL STATUS : ccs Sie 1% ‘Tanda rangsang meningeal/ Meningeal sign Brudzinski 1/ Brudzinski I sign Kaku kuduk / Neck stiffness Tanda Laseq / Laseque sign CO Tanda Kernig / Kernig sign Brudzinski Il / Brudzinsgi IT sign SarafKranialis / Cranial nerve f © Kanan Kiri Nervus I: gangguan menghidu /Olfactory Disorders : (2) Asiqruran ‘Nervus II: ‘Visus / Vision ‘Kampus/lapang pandang (konfrontasi test) / Visual field : ‘Warna / Colour Fundus / Fundus ® ditetucan , Nervus Ill, IV, VI Sikap bola mata OMfofoma CebhPalpebra hora, Pupil : ukuran, bentuk (Size, shape) >!™"/30%, GUAK, sory Reflex cabaya langsung / Direct light reflex Reflex cahaya tidak aes aes light reflex y th Reflex konvergensi / Conver Nistagmus / Nystagmus /— Pergerakan bola mata / Eye movement, Nervws V + ‘Motorik / Motoric Inspeksi/ Inspection Yiwneress - Palpasi / Palpation’ ~~ wyrnqorowr Membuka mulut / Open mouth © Gerakan rahang/Jaw movement ‘Sensorik / Sensoric ilitas V1 /V1 sensibility ‘Sensibilitas V2 /V2 sensibility ve Sensibilitas V3 /V3 sensibility Reflex kornea / Corneal reflex “<7 @ a#varurar Hanya untuk Kebutuhan pendiikan For educational purpose only ‘STH 409.4018 Scanned with CamScannerSESE agai | QUEH Student Record Nerves Vil Sikap mulut itirahat / Resting mouth movement Angkat als, kerut dahi, tutup mata dengan kuat / Fives . Kembung pipi ‘Menyeringai Rasa kecap 2/3 anterior lidah —> @® dutla ruran Nervus VIE \ ‘Nervus cochlearis ‘Suara gesekan jari Rinne ieee YQ a tarsae ‘Schwabach Nerws vestibularis Nitagms 7 Derdiri dengan satu kaki: Mata tertutup (Stand with 1 feet: Close eye) @ Mata terbuka (open eye) Berdiri dengan 2 kaki: Mata ‘tertutup emir ‘Mata terbuka’ Berjaln tandem Fkua stepping test Past pointing test N.IX,X Arkus faring / Pharynx arch nterecc~ Uvuh Bt toed, Disfoni/ Dysphony Disgi/Dysphagy & . Reflex firing / Pharynx Gee > @ anatuean . N.XI Sternocleidomastoid y mM) . tae © NXIL Sikap lidah dalam motut Deviasi / Deviation Auofi Atrophy Fasikxulasi / Fasciculation ‘Tremor / Tremor Hanya untuk kebutuhan pendidikan / Fer educational purpose ony STH 1403.1071 Scanned with CamScanner. SESS sicutie| QUPH Student Record Menjulurkan tidal % @ Kekuatan tidal MOTORIK / MOTORIC remitas Atas / Upper Exiremity Inspeksi / Inspection Awofi | Atrophy © Fasikulsi/ Fasciculation (>) Palpasi: tones (Palpation: Tone) WsernohS Kekuatan / Power sndi bah / Shoulder Joint Biceps ‘Triceps: Pergelangan tangan/ Hand movement Extensi Jari / Finger extension oom | or Menggenggam/ Grasp Gerakan involuservolinter Movement Extremitas bawah / Lower Extremity vss Inspeksi Inspection ‘Auofi / Atrophy Fasikubsi / Fasciculation Palpasi ; tonus ( Palpation : Tone ) Wo bos” Kekuatan / Power Gluteus Hip flexor Quacdriceps hamstring cane ‘Ankle dorsi flexi Gastrocnemius, Gerakan involuner/ involunter Movement = G2. Refleks fsiologis / Physiologic Refles : Biceps Triceps ake KPR 42 5 APR Refleks patologis / Patologic Reflex = Babinski haddock Lr Oppmntsin Gordon Hanya untuk kebutuhan pendkan For educations! purpose only STH 1403.10 Scanned with CamScannerSIRERISTESaeS Student Record ‘Schaffer Rossolimo LL Mendel Becthrew ‘Hoffman Trommer SENSORIK / SENSORIC Eksteroseptif. Raba —> ae ditaeutan sin YO Propioseptit Posisisendi —> Gear —> G) etttakuran KOORDINASI / COORDIANTION Tes Tunjuk-Hidung Tes Tumit-Lutut @. Distiadokokinesis OTONOM Miksi Defekasi Yu OO: Sekresi keringat FUNGSI LUHUR : MMSE @ anatuean. agicee| QUPH ex dig dm Felton MRM Piiggag 2 faxemuton otf SFETTMy, [ee ef bin Sixt RESUME:— Baterae . DIAGNOSIS / DIAGNOSE Kllinis / Clini Topis /Topic: + Setakeo. Btiologi / Etiology: wnguawn Patolgis/ Patology: gatrap mend - qederta — menrlarnese ere PX dium lama, melon 3 mye fy, foe 1: Newt Got pur'formate nye’ puqgay, Fetemetin Ah GO BOEPS, Paha 2 Lene, Hanya untuk kebutuhan pendkan |For educational purpose only ‘STH 1403.1071 Scanned with CamScanner‘mee - SEEMS ngsicie| QUPH Student Record DIAGNOSIS KERJA / WORKING DIAGNOSE Rywiformy Syncinome — DIAGNOSIS BANDING | DIFFERENTIAL DIAGNOSE Luumbare Rech anlar as, 4 ant. PROGNOSIS / PROGNOSE Ad vitam a ee 4 Ce Ad sanationam SARAN PEMERIKSAAN PENUNJANG/ wpe wha Lumbar . SARAN TERAPI / THERAPY SUGESSION nal het | en sors, Wed Spemnre 7% —— Mtpenn AK 300%HG- When. 2¥ ROMY ‘Nama dan ttd mahasiswa/ Student's name and signature PreceptoriPrecepior Cc C Brayjfana Te) C ) ‘Hanya untuk kebutuhan pendidikan |For educations! purpose only 8TH 1403.50" Scanned with CamScanner