SEEN uesient | QUPH Student Record LEMBAR KASUS STATUS NEUROLOGI / NEUROLOGY CASE SHEET Status Lengkap / Complete Status Identitas Pasien / Patient Identity Spoons bbe. Trisial Pasion / Pationt Initial Kolamin / Sex Tanggal Lahir/ DOB Status Perkawinan’ Marital Status: ~ ‘Agama | Religion Pendidikan / Educational Stetus ‘Atamat | Addroos Keluarga Yang Bisa Dihubungi Family Contact Number Pekerjaan / Occupation Tanggal Masuk RS /Date of Admission: ‘Yi, /y, Jam/Time = Tanggal Pemeriksaan / Date of Examination : Yo /,, Jam /Time t C Autoanamnesis 1) Alloanamnesis dari CO Autoanamnesis (1 Alloanamnesis from... Tanggal Pulang /Date of Discharge : “/a/w Jam/ Time: —————— ANAMNESIS (alloanamnesis/autoanamnesis) Re aetna dan euler SAU Ferate 96 wemberat copae tn 6, RIWAYAT PENYAKIT SEKARANG / Present Illness History: i dig dan wwulen saktt REPU vy remberat PRA ay. say Fale Wilers Blt 2 Prolad! doer ganar ciel , RALORYA GRRE ngambans caag CORAM. je ada viv TA goad + bin vb Gm tetemchan pata angyora seraie Fanan. f Gl Wena FO BIN dame ff & betureRg race Jaminye, PR Ssh weeacuran cor (et 2 wsl © - KELUHAN UTAMA / CHIEF COMPLAIN : Bus op soptin &, REA wyeludean sees Fgsen . RIWAYAT PENYAKIT DAHULU / Past Illness History : TIA dg oMohan arepore quam Fanan Shin yl WO MO ag CO ‘Hanya untuk kebutuhan pendiikan For educations! purpose only ‘STH 1403.10 Scanned with CamScannerSEES acuriee | @QUPH Student Record RIWAYANR KQRLUARGA / Family History: @ odo vy mewuities qeoato fenugo. RIWAYAT SOSIALIKEBIASAAN/POLA HIDUP (Social History /Life style ): ° PEMERIKSAAN FISIK / PHYSICAL EXAMINATION STATUS GENERALIS Keadaan umum / Genera! Appearance: 1S Tehanan darth Blood Pressure : Po/vw Nadi Heart ate Kesadaran / Consciousness Pemapasan/ Breath Pg ‘Suhu/ Temperature Kepal /Head _worryocepiati Mata / Eve PAPC toutes, (borer, am /3m. of. i Te THT /ENT Secrer © + Loker Neck pnbesaron ep © - Thom! Thorax pergembongen aoolo Sits Para / Lung yer ta, Met, wT Jantung/Cor BS ray, OVS) Abdomen / Abdomen Qu@, M G- Punggung/ Back —_teformitas ©). Extremits/Exremity aereg Qurges, C83 2 SOE Hanya untuk kebuttan penighkan | For education! purpose only ‘StH 103.1011 Scanned with CamScannernigbicixe | QUPH Student Record STATUS NEUROLOGIS / NEUROLOGICAL STATUS : Ges MG YIIG ‘Tanda rangsang meningeal/ Meningeal sign Kaku kuduk / Neck stiffness Tanda Laseq / Laseque sign Tanda Kerig / Kernig sign iG Brudzinski / Brudzinski sign Brudlzinski Ml / Brudzinsgi I sign SarafKranialis / Cranial nerve Kanan Kiri Nervas 1: gangguan menghidu /Olfactory Disorders: @) ardarurat Nerws I: Visus / Vision Kampus/lpang pandang (konffontasi test) / Visualfield; @ dakar Warra / Colour Fundus / Fundus Nervus Ill, 1V, VI Sikap bola mata orteGoria tilaterad Colah Palpebra Pupil : ukuran, bentuk (Size, shape) 30/200, Inuiag , \EOKOr ~ Reflex cahaya langsung/ Direct light reflex. 44 4 Reflex cahaya tidak langsung / Indirect light reflex 4/4 Reflex konvergensi / Convergency reflex. +44 Nistagmus / Nystagmus = —J— Pergerakan bola mata / Eye movement eS Heber he alr ch Nerms V Motork / Motoric Inspeksi/ Inspection yorrrotrogs | noewotrag Palpasi /Palpation — nvorvvojowar/ Wormetoine Menbuka must /pen mouth % dsfakutan - Gerakan rahang/ Jaw movement Sensorik / Sensoric Sensibilitas VI /V1 sensibility Sensibilitas V2 /V2 sensibility y dln Sensibilitas V3 /V3 sensibility Reflex kornea / Corneal reflex. > @ avianuran ‘Hanya untuk kebutuhan pendidikan For educational purpose only ‘STH 1408.40/1 Scanned with CamScannerStudent Record Nerves VII ‘hap nul tira / Resting mouth movement Angkat ais, kerut ahi, Qi tutup mata dengan kuat / Kembung pipi Menyerimgai : rasa hecap 2/3 anterior lidah —> @) cbi@acettor- Clroveteck 89s Nervis VII Nenus cochlear Sina gectan jai, AOD” Rinne Weber jo datotuion Schwabach 6/0 Nervus vestibularis Nistagmus “f- Pendiri dengan satu kaki: Mata tertutup (Stand with 1 feet : Close eve) Mata terbuka (open eye) Beni dengan 2 kaki: Mata tertutup Mata terbuka @ Hlatucon. Derjalan tandem Fukuda stepping test Past pointing test NAIX.X Arkus faring /Pharynx arch 8wOteac uvul at ray. Disfoni/ Dysphony Disfagi /Desphagy © Reflex faring / Pharynx refler =, @ Ai leratan . N.XI Sterockidomastoid % Ay ‘Trapezius NXIL Sikap lidah dalam mulut Deviasi / Deviation ©) Awrofi / Atrophy Fasikulasi/ Fasciculation © Tremor/ Tremor — Hanya untuk kebutuhan pendlsikan | For educational purpose only ‘STH 1403.10 Scanned with CamScanner< Siloam ssHaspiias gszige| @UPH Student Record Menjulurkan lida A" Kekuatan fidah = Ue MOTORIK / MOTORIC Extremitay Mas / Upper Extremity Inspeksi / Inspection Atrofi / Atrophy: Oo Fasikulsi / Fasciculation Palpasi : wonus ( Palpatio Kekuatan/ Power — 3 Sendi bahu/ Shoulder Joint Tone) Worimotous - Biceps Triceps, oar sour Pergelangan tangan/ Hand movement Extensi ari / Finger extension oo foo Menggenggam / Grasp Geral wolunter/ Jnvolunter Movement Extremitas bawah / Lower Extremity Inspeksi / Inspection Attofi/ Atrophy — © Fasikulsi/Fasciewlation ©) tonus (Palpation : Tone) — wor totyus ‘Power @®* luteus Hip flexor Quadricops hamstring Ankle dorsi Gastrocnemias Gerakan involunter/ Involunter Movement > oda « Reflcks fisiologis / Physiologic Reflex Biceps Triceps KPR 3/42 APR Reflcks patologis / Patologic Reflex Babinski Chaddock Oppenheim i Gordon Hanya untuk kebutuhen pendicikan {For educational purpose only ‘STH 1403.10 Scanned with CamScannerSESS assieiee| @UPH Student Record Schafter Rossolino 7 Mendel Becthrew Mofiinan Trommer SENSORIK / SENSORIC Eksteroseptit’ Raba —= dm Nyeri Sia; 2d: aiaenben Propioseptif Posisisendi —* bn Gear + @ astarucer KOORDINASI/ COORDIANTION ‘Tes Tunjuk-Hidung ‘Tes Tumit-Lutut ¥ @ aharutan Disdiadokokinesis OTONOM Miksi Defekasi Y abn . Sckresikeringat ———* @ dierucan LUHUR : FUNGSI LUH eur Sais topala Y wembral DAE Ie. Sat Mept fr MMSE (¢) ne pit fe warn 2 FH. ae | Womans Set ferpaln . Px nengemran sony vingsan ee TA hn te la dan eeluban — betemabon aigpote, pra RESUME: venan. Wee PEE RGIS ach ictal obser ag th. DIAGNosIS /DIAGNosE ® f°9% Pe Laine @- Klinis / Clinic = Topis / Topic Btiologi / Etiology : Patologis / Patology : al purpose onl jondicikan |For education ebutuhan Be ‘STH 1403.40 Hanya untuk Scanned with CamScannerase neve: | QUPH Student Record DIAGNOSIS KERJA / WORKING DIAGNOSE Hrasmofive DIAGNOSIS BANDING | DIFFERENTIAL DIAGNOSE PROGNOSIS / PROGNOSE ‘Ad vitam + Bowam Ad functionam —: Arowom Adsanatiomm ; due od bona SARAN PEMERIKSAAN PENUNJANG / SARAN TERAPI / THERAPY SUGESSION Cattium Lactate \x 90 “4 Gpusitore ox $0 mi Sypraz 1 OF 5, > Aprazaom , ‘Nama dan tid mahasiswa/ Student's name and signature Lo Opie GLE0M PreceptoriPreceptor Hanya untuk kebutuhan pendidikan | For educational purpose oly STH 1403.10 Scanned with CamScanner