Modul Skills Lab Nbss 2017-2018 Th.2 (Revisi 20 Nop 2017) - 1

STUDENT HANDBOOK
SKILL,S LAB
NEUROBEHAVIOUR AND SPECIAL SENSES
SYSTEM ( NBSS )
SECOND YEAR OF UNDERGRADUATE

PROGRAM FACULTY OF MEDICINE
PADJADJARAN UNIVERSITY
2017-2018
1
CONTENTS :
TOPIC 1: INTRODUCTION, MOTORIC, AND SENSORIC EXAMINATION ………

TOPIC 2: REFLEXES AND MENINGEAL SIGNS EXAMINATION …………………
TOPIC 3: CRANIAL NERVES EXAMINATION ……………………………………….
TOPIC 4: GCS EXAMINATION AND MMSE ………………………………………….
TOPIC 5: DEVELOPMENTAL REFLEXES ……………………………………………..
TOPIC 6: KUESIONER PRA SKRINING PERKEMBANGAN ( KPSP )
………………
TOPIC 7: BASIC HEARING EXAMINATION ……………………………………….
TOPIC 8: EYE EXAMIANTION …………………………………………………………
TOPIC 9: HT. in PSYCHIATRY EXAMINATION .........................................................
TOPIC 10: PSYCHIATRICT EXAMINATION………………………………………….
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TOPIC 1
SKILL LABORATORY PRACTICE MODULE
BLOCK : NEUROBEHAVIOR AND SPECIAL SENSE SYSTEM
TOPIC : INTRODUCTION, MOTORIC, AND SENSORIC EXAMINATION
INTRODUCTION
LEARNING GUIDE
NEUROLOGICAL EXAMINATION
I INTRODUCTION
1 Greet the patient and introduce the examiner’s self,

develop a good rapport with the patient
2 Ask the patient’s identity
- The patient’s name
- The patient’s age
- The patient’s work
- The patient’s residence
II CHIEF COMPLAINT
1 Ask the patient why she/he come to clinic
2 Ask the date of onset
- Whether the onset was sudden or insidious
- Whether the patient was unconsciousness, fever,

headache, vomit or convulsive
- The precipitating or risk factors
- The course of illness
III GENERAL EXAMINATION
1 - Assess the patient’s level of consciousness, blood

pressure, pulse rate, temperature and respiration
2 - Assess the cardiac and pulmonary condition
3
IV NEUROLOGICAL EXAMINATION
1 Cranial nerve examination
- N. I (smell function)
- N.II (visual acuity, visual fields)
- N.III, IV and VI (eye movement)
- N.V (sensory and motor function)
- N.VII (motor and sensory function)
- N.VIII (auditory and equilibrium function)
- N. IX and X (swallowing function)
- N.XI (motor function)
- N.XII (taste and motor function)
2 Motor function examination (extremities)
Level of strength, tonicity (spasticity, rigidity),

athrophy.
3 Sensory function examination.
- Exteroception sensory function.

- Propioception sensory function
4 Outonomical nerve function examination.
- Bladder and bowel function.(vegetative function)

- Other outonomical nerve function
5 Reflexes examination
- Physiological reflexes
- Pathological reflexes
- Regressive/primitive reflexes
6 Cortical higher function examination
- Mental function
(Mini Mental State Examination / MMSE)
- Aphasia (motor and sensory aphasia)

- Agnosia
V LABORATORY EXAMINATION
1 The lumbar punction examination test
2 Funduscopy examination
3 Electroencephalography (EEG) examination
4 Electromyography (EMG) examination
5 Laboratory Finding examination
4
6 Neuroimaging examination (CT-scan, MRI, PET, SPECT)
NEUROLOGIC EXAMINATION
EXAMINATION OF MOTOR FUNCTION
No. Step 0 1 2
1. The examination of motor function include
inspection, strength and tones of limbs and
percussion for detecting fasciculation
2. The examiner inspect the motor condition of

upper and lower extremities.
3. The contour and muscle development of the two

side should be equal.
4. During this inspection also detect the muscle

wasting, the presence of fasciculation and
involuntary movement of the limbs
The strength of limbs.
5. The patient is asked to elevate and contract of

muscles of upper extremity against resistance of
examiner’s hand
5
6. The examiner notice the grade of strength of
limbs.
Grade 5. The patient can against the full

resistance of the examiner’s hand equally
(normal patient).
Grade 4. The patient can against only light

resistance of the examiner'’ hand.
Grade 3. The patient can only against the

gravitation resistance.
Grade 2. The patient can only move the limbs

over the bed.
Grade 1. The patient cannot move the limbs but

just move the fingers.
Grade 0. The patient is total paralysis

(paraplegia)
7. The same manner for examining the lower

extremity.
The tone of muscles

8. The patient is asked to relax the muscles of limbs
9. The examiner flex and extend passively the

patient’s joint of limbs and felt the muscle
resistance,
Abnormal response is the increased of tonicity of

the muscles.
Comparing the tone’s limb muscles of two side
The fasciculation
10. The examiner percuss on one area of limbs.
6
11. The examiner notice the fasciculation moving of
the muscles on the area of examination
(Fasciculation is the contraction of some group of

muscles)
(EXAMINATION OF SENSORY FUNCTION)
0 1 2
Tests of sensory function are concerned with

appreciation of primary or cutaneous sensation and
evaluation of cortical integration of sensory
impulses.
The sensory function is include exteroception

sensation tests (light touch, pain and temperature)
and propioseption sensation tests. (vibration sense
and position sense).
Exteroception sensory examinations.

I
1 Light touch.
The patient sits or lies with hand supinated, and

he/she is asked to close the eyes and is instructed
to answer “yes” when the stimulus is appreciated.
The examiner takes a wisp of cotton and applies it

lightly to the skin, and alternates between the two
sides, examining the homotopic area
The cotton is applied to the skin of the neck

beginning in the C3 dermatome on each side and
passing down the neck to the shoulder and the
lateral aspect of the arm and forearm to the hand.
The fingers are tested individually.
7
The stimulus is then applied up the medial aspect
of the forearm and upper limb to the chest.
Sensation in the lower limb is examined in a similar

fashion with an alternating application of the
cotton down the lateral aspect of the thigh, leg and
foot, and up the medial aspect of the foot, leg and
thigh
2 Pain and temperature sensation tests are

examined in a similar fashion.
Pain sensation is tested with pinwheel or needle.
Temperature sensation is tested with glass tube

filled with hot or iced water
II
Propioception sensory examinations.
1 Position sense.
Position sense is tested by gently moving a

terminal phalanx of toes or fingers
The patient is asked to close the eyes
The examiner grasps the terminal phalanx in the

sides and gently moves it a few degrees in an
upward or downward direction.
The patient is asked to indicate whether the digit is

moved up or down.
Compare the two sides with the similar test.
2 Vibration sense.
The patient is asked to close the eyes
8
The examiner places the base of a tuning fork over
a bony prominence.
The patient is asked to indicate whether the

sensation of vibration is appreciated or not
The similar test is carried out in the other side and

compare the both sides.
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TOPIC 2
TOPIC : REFLEXES AND MENINGEAL SIGNS EXAMINATION
(EXAMINATION FOR REFLEXES)
No Step 0 1 2
Physiological reflexes
I
Biceps reflex
1
The patient lies and is instructed to relax.
The examiner takes the patient’s arm and flexes the elbow
joint, and places over the abdominal area.
The examiner places the index finger on the patient’s biceps

tendon and gently strikes the finger with the reflex hammer.
The result is produce contraction of the biceps muscles and

flexion at the elbow
The response on the two sides is compared.
Triceps reflex
2
10
After preparing the patient as same as the biceps reflex test,
the examiner flexes the elbow to 900 and elevates the elbow
joint slightly and then strikes the triceps tendon with reflex
hammer
This produce contraction of the triceps muscles and extension

of the elbow
The response of the two sides is compared
Brachioradialis reflex
3
The patient’s arm is lied beside the body.
The examiner hold the patient’s lower arm and strikes the
wrist joint with reflex hammer.
The result is produce the contraction of brachioradialis with a

flexion movement at the elbow.
Knee jerk reflex / Patellar réflex

4
The examiner flexes the patient’s leg at the knee joint and
places the hand below the knee and against the leg.
The examiner strikes the patellar tendon at the knee joint.
This produce extension reflex of the lower leg

Achilles tendon reflex / Ankle tendon reflex

5
The examiner places one patient’s leg above another one and
bend the foot at ankle joint. in dorsal flexion
The examiner strikes the achilles tendon with reflex hammer.
This produce plantar flexion of the foot
6 Superficial reflex (Abdominal reflex)
11
The patient opens the clothes over the abdominal area of the
body
The examiner strokes the skin of the abdomen gently with the
base of reflex hammer. The skin is stroked in a diagonal
fashion moving downward lateral to medial toward the
midline.
The sites of stimulation are the above of umbilicus, at the

level of umbilicus and the below of the umbilicus.
Pathological reflexes
All pathological reflexes in the lower extremities produce
extensor plantar response, is a dual response consisting of
extension of the hallux (the first digit of toes) and extension
of the other toes which separate in a fan-like fashion.
Exception for Rossolimo and Mendel Bechterew reflexes, the
results are the contraction of the toes.
Babinski reflex
The examiner holds the patient’s foot at ankle joint and
stimulates with scratching the lateral aspect of the sole of the
foot with the blunt object (the base of reflex hammer).
The movement is carried out along the lateral aspect of the

sole of the foot and then across the head of metatarsal bones
The examiner notice the reflex response
Chaddock reflex
The examiner strokes the lateral aspect of dorsal foot
from posterior to anterior across the head of metatarsal
bones with the blunt object.
Oppenheim reflex
The examiner places the flexed forefinger and middle finger
on the proximal tibial bone, then moves downward with
pressure until the edge distal of tibia.
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Gordon reflex
The examiner presses the gastrocnemius muscles with less
strength
Scheiffier reflex
The examiner presses the achilles tendon
Rossolimo reflex
The examiner percusses the anterior aspect of plantar pedis
with reflex hammer
The pathological response is contraction of the toes
Mendel Bechterew
The examiner percusses the anterior aspect of dorsal pedis
with reflex hammer
The pathological response is contraction of the toes
Hoffman Tromner reflex

The examiner takes the patient’s index and middle finger and
places on the same fingers of the examiner
The examiner strikes the terminal phalanx of these patient’s

fingers with the examiner’s finger
The result is the contraction of the fingers
Primitive reflexes
Glabellar reflex
Examiner taps gently the forehead in the midline just above
the bridge of the nose
The stimulus should be come from the outside of the visual

field ( to prevent the threatening response)
13
Normal response is rhythmic contraction of the eyelids which
disappears after e few seconds. Usually do not more eight
contractions
Palmo-mental reflex
The examiner strokes the palm of patient’s hand at the lateral
aspect of metacarpal area of digit one downward from
proximal to distal.
Abnormal response is the contraction of mental muscles in the

ipsilateral chin
Snout reflex
The examiner taps the face between the upper lip and the
nose gently with the finger
Abnormal response is a pursing of the lips to each stimulus
Grasp reflex
The examiner grasps the patient’s hand as if to shake hands
and then strokes the palm of the patient with his finger
Abnormal response is the patient’s finger flex and grasp the

examiner’s fingers.
(MENINGEAL SIGNS EXAMINATION)

1 Neck stiffness (Nuchal rigidity) 0 1 2
The examiner flexes the patient’s head until the chin

contacts the chest (sternum)
Abnormal response is the examiner felts the resistance of

head movement and the patient shows painful expression.
2 Brudzinki’ssign
There are three types of Burdzinski’s signs. Abnormal

response is the flexion of the leg at knee joint
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Brudzinski I (Brudzinski’s neck sign)
− The examiner flex the patient’s head and notice

the flexion movement of the leg
Brudzinski II (Brudzinski contralateral leg sign)
− The examiner elevates one leg of the patient

upright and notice the flexion movement in
another ones
Brudzinski III (Brudzinski’s cheek sign)
- The examiner press the zygomatic

bones to see if the patient will flex his/her upper
arms
Brudzinski IV (Brudzinski’ssymphysis sign)
− The examiner press the lower part of abdomen

(suprapubical area) and notice the flexion
movement of the leg
Lasique’s sign
The examiner elevates the leg of patient upright
Abnormal response is if the patient felts painful at leg

angle (the angle between the leg and the surfaceof bed)
less than 70o
Kernig’s sign
The examiner elevates the patient’s leg and flex 90o at hip
and knee joints, then extend the lower limb at knee joint.
Abnormal response is if the patient felts panful at knee

angle less than 130o
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TOPIC 3
TOPIC : CRANIAL NERVES EXAMINATION
CRANIAL NERVES
No. Step 0 1 2
1 N.I. (OLFACTORY NERVE)
The patient is asked to inhale with one nostril occluded
The examiner brings the test substance close to the nonoccluded

side.
The test substance :
- must be nonirritating
- such as coffee, tobacco
Each nostril is test separately
The examiner notes that inhalation is adequate, then requests the

patient to identify the test substance.
2 N.V (TRIGEMINAL NERVE)
Examination of N.V includes:
- evaluation of corneal reflex

- sensation of the face and scalp
- motor function
- the jaw reflex
2.1
Evaluation of corneal reflex
(This reflex is tested by the light application of cotton to the
limbus of cornea)
The examiner takes a cotton applicator and pulls the

cotton head into a fine point.
16
The patient is asked to look upward and the cotton is
brought toward the eye from a lateral position and
gently applied to the limbus of cornea
The result :
The application should produce a prompt bilateral reflex closure
of the eyelids. The response is compared on the two sides.
2.2
Sensation over the face and scalp.
The patient is asked to close the eyes and to respond if

touched.
The cotton is applied to the forehead on one side,

followed by application to the forehead in a similar
position on the other side. Then to the cheeks on the
two sides, the to the jaws on the two sides.
The patient’s responses are monitored and the patient

is asked whether the sensation appears to be equal on
the two sides of the face
The same test is then repeated using a sharp pin with a gentle
application
2.3 Motor function
The examiner places the fingers over the temporalis muscles.
The patient is asked to clench the teeth or bite and the examiner
will felt the contraction of the temporalis muscle under the
examiner’s hands on both sides.
A similar test is performed over the masseter muscle
2.4
The jaw jerk reflex
The examiner tap the anterior lower jaw with the reflex hammer
A normal response is a slight upward movement of the mandible,

and in an abnormal response is increased upward movement of
the mandible.
3 N. VII (FACIAL NERVE)
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Examination of N.VII is include :
- Motor function of facial muscles.

- taste sensation of the anterior two-thirds of the tongue
3.1
Motor function of facial muscles
- lower facial muscles test
- upper facial muscles test
1. Lower facial muscles test:
The patient is asked to grimace and show the teeth
In a normal response, the mouth angles have to in symmetrical

position. In an abnormal response, the mouth deviate to the
normal side
2. Upper facial muscles test.
The patient is asked to close the eyes tightly
The examiner attempt to open the lids.
(in a normal patient, it is not possible even when the examiner

uses considerable force)
The patient is asked to move upward of his/her eyebrow.
In a normal response, the wrinkles of forehead are symmetrical

in two side. In an abnormal response, there are not wrinkles of
forehead in abnormal side.
3.2 Taste sensation of the two-third anterior of the

tongue.
There are four forms of taste sensation: sweet (sugar), sour
(vinegar), bitter (quinine) and salty (salt). All these test
substances should be prepared in solution forms.
Prepare one paper which be divided in four area by two cross

line. Write in each area one form of taste sensation
The patient is asked to protrude the tongue and should be hold

during this examination
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The examiner is gently apply a test substance on the tongue with
a cotton applicator
The patient signals when the test substance is identified and then
can point out the kind of taste sensation on the paper. Do not use
verbal communication.
4 N.IX (GLOSSOPHARYNGEAL NERVE)
N.IX examination is include:
- Taste sensation of the one-third posterior of the tongue.

- Gag reflex examination
Taste sensation of Tenth Nerve is tested in the same manner as
taste sensation of Seventh Nerve.
Gag reflex examination

The patient is asked to open widely of the mouth
The examiner stimulate the pharyngeal wall with tongue spaltel

on each side
The examiner notice the gag response
5 The Tenth Nerve (Vagus Nerve)

The Tenth nerve examination is include:
- The changes of the speech

- The contraction of the soft palate
- Dysphagia
The changes of speech
The patient is asked to speak a sentence or some words.
The examiner notice the change of the patient’s speech whether

dysphonia or dysarthria.
Dysphonia is difficulty in phonation due to paralysis of vocal cord.

The voice is hoarse and the volume reduced. Dysarthria is
difficulty in articulation due to vagal paralysis results in weakness
of the soft palate.
Examination of the soft palate

The patient is asked to open the mouth and say “Ah”
The examiner notice the contraction of the soft palate in the both
side and the ovula position.
19
In normal response the soft palate in both side (the arching of
the palate / arcus palatum) elevate symmetrically and the ovula
remain in the midline.
In abnormal response the soft palate does not elevate in affected

side and the ovula is drawn to the opposite side.
Dysphagia
The patient is asked to swallow some little food
The examiner notice the difficulty in swallowing and the patient is

choked.
6 The eleventh Nerve (Accessory Nerve)
The eleventh Nerve examination is motor function test of the

sternocleidomastoid and trapezius muscles
The strenocleidomastoid examination

The patient is asked to turn the head to one side against
resistance by the examiner’s hand
The examiner palpates the sternocleidomastoid muscle in the

opposite side and felt the contraction of the muscle. This
examination is also performed in other side.
The trapezius examination
The examiner place both hands on the patient’s shoulder

and palpating the trapezius muscle on each side
The patient is asked to elevate the shoulder against the
examiner’s resistance.
The examiner notice equality of contraction the both
muscles.
7 The Twelfth Nerve (Hypoglossal Nerve)
The Twelfth Nerve examination is pure motor test.
The patient is asked to open the mouth and the tongue

remain lying on the floor of the mouth
The examiner notice whether there are fasciculation and
atrophy of the tongue’s muscles or not, and then
The patient is asked to protrude the tongue
The examiner notice whether the tongue deviate to one

side. The paralyzed tongue deviates toward the side of
motor neuron lesion (affected side).
20
TOPIC 4
TOPIC : GCS EXAMINATION AND MMSE
Level of Consciousness
Level of Consciousness:
- Compos Mentis (GCS = 15)
- Somnolen (GCS = 12 – 14)
- Sopor (GCS = 8 – 11)
- Coma (GCS = 3 – 7)
GCS = Glasgow Coma Scale (Scale ranges from 3 – 15 )
0 1 2
1. Eye opening
E 4 = Spontaneous
The patients spontaneously open his/her eyes without
any stimulation
E 3 = To sound
The patients open his/her eyes to sound stimuli (when
you ask to open his/her eyes or called his/her name)
E 2 = To pain
The patients open his/her eyes when you give pain stimuli by
pressing his/her chest or supraorbital
E 1 = Never
The patients never open his/her eyes even you give pain
stimuli
21
2. Motor response
M 6 = Obey commands
The patients obeys your commands if you asked him/her
something to do
M 5 = Localizes pain
The patients attempt to localized the pain when you give

pain stimulation on his/her chest or supraorbital
M 4 = Normal flexion
The patients extremities were normally flexing when you give

pain stimulation (with drawl)
M 3 = Abnormal flexion
The patients extremities were abnormally flexing when you

give pain stimulation on his/her chest or supraorbital
M 2 = Extension
The patients extremities were abnormally extend when you

give pain stimulation on his/her chest or supraorbital
M 1 = Nil
There was no motor response to pain stimulation
3. Verbal response
V 5 = Oriented
The patients could talk appropriately with you
V 4 = Confused conversation
The patients could not talk appropriately with you
V 3 = Inappropriate words
The patients just only produce inappropriate words
V 2 = Incomprehensible sound
The patients just only produce Incomprehensible sound
V 1 = None
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MINI MENTAL STATE EXAMINATION ( MMSE )
Orientation
• Time : Year Month Day Date Time ( 1 point

for each correct )
• Place : Country Town District Hospital Ward
( 1 point for each correct )
Registration
• Examiner names 3 objects (e.g. Apple, Table,

Penny)
• Patients ask to repeat (1 point for each correct)

• THEN patients to learn the 3 names repeating
until correct
Attention and Calculation
• Subtract 7 from 100, and then repeat for results.

• Continue 5 times : 100 93 86 79 65
• Alternative : Spell “WORLD” backwards ,
“DLROW” (1 point for each correct)
Recall
• Ask for names of three objects learned earlier

(1 point for each correct)
Language
• Named a pencil and watch (1 point for each

correct)
• Repeat : No if, ands, or buts (1 point if
correct)
• Give a 3 stage command. (Score 1 point for
each stage correct)
Eg. “Place index finger of right hand on your
nose and then on your left ear”.
• Ask patients to read and obey written command

on a piece of paper stating “ Close your eyes”
(1 point if correct)
• Ask the patients to write a sentence. (Score 1
point if it is sensible and has a subject and a
verb)
23
Copying
• Ask the patients to copy a pair of intersecting

pentagons. ( 1 point if correct )
TOTAL =
5 + 5 + 3 + 5 + 3 + 2 + 1 + 3 + 1 +1 +1 = 30
24
TOPIC 5
TOPIC : DEVELOPMENTAL REFLEXES
GENERAL OBJECTIVES
At the end of skill practice, the student will be able to demonstrate how to eliciting developmental
reflexes including primitive reflexes.
METHODS
• Presentation
• Demonstration
• Coaching
• Self practice
EQUIPMENT
• Learning guide
• Mannequin
REFERENCE
Swaiman KF. Neurologic examination after the newborn period until 2 years of age.
Dalam: Swaiman KF, Ashwal S, Ferriero DM, penyunting. Pediatric neurology. Edisi ke-
4. 2006. USA;Mosby Elseveir; hlm 37-46.
LEARNING GUIDE
DEVELOPMENTAL REFLEXES
Introduction
Developmental reflexes are patterned responses that are achieved by certain ages. General
development of the nervous can be assessed by eliciting these reflexes. The abnormalities may be
the continued presence of a reflex that should have system dissipated, absence or poor
manifestation of the expected response or a response that is not symmetric. Primitive reflexes are
stereotypic motor responses to various stimuli that develop before birth and disappear during early
infancy in a predictable pattern.
Those reflexes are palmar grip, plantar grip, gallant, asymmetric tonic neck, suprapubic extensor,
crossed extensor, rossolimo, heel, moro and babinski.
25
Not all reflexes discussed.
0 1 2
GALANT REACTION
1.
Put the baby in prone position
Scratching the skin of the infant’s back from the shoulder

downward 2-3 cm lateral to the spinous processes
If the child is stroked paravertebrally with one finger , its body

curves.
The concavity proceeds toward the direction of the stimulus;

the pelvis is raised.
The corresponding leg and arm are stretched, the opposite

extremities are curved.
This reaction is often also called the spinal reaction.
Disappear at age 4 month
GLABELLA REACTION
2.
Put the baby in supine position
Applied a pressure to the middle of the forehead
The reaction is both eyes will closed.
MORO REACTION
3.
Lay the child upon one forearm and support its head with the
other hand
Than the hand holding the child’s head is lowered.
The child’s head falls into the opened hand.
The child opens his mouth, the arms are lifted and opened, his
fingers are stretched apart like a fan.
26
Then the mouth is closed again, the arms are bent and joined
together again in front of the child’s body.
ASYMMETRIC TONIC NECK REACTION

4.
Rotation of the infant’s head to one side for 15 seconds
If the child’s head is turned to one side , the extremities of the’

facial side’ are stretched, and the extremities of the ‘occipital
side’ are bent.
This is the so called “ fencer’s position”.
PALMAR GRASP REACTION

5.
Placing the index finger in the palm of the infant
The reaction is flexion of fingers, fist making
As long as the stimulus remains, the hand may remain closed.
PLANTAR GRASP REACTION

6.
Pressing a thumb against the sole just behind the toes
The reaction is flexion of toes
When the contact is removed, the toes spread apart
PARACHUTE REACTION
7.
27
The examiner’s holds the infant with both hands around the
waist at the trunk and lowers its head relatively fast to the
surface below.
Before the head reaches the surface the arms are extended
( optical readiness to jump), and later the transfer of body

weight to the arms occurs.
Appear at 9 month old
8. Crossed Extensor
Passive total flexion of one lower extremity
Extension of the other lower limb, with adduction and internal

rotation into talipes equines
Disappear at age 6 weeks
Scoring system
0 : If student didn’t do the instruction
1 : If student do the instruction but not correct
2 : If student do the whole instruction with correct
28
TOPIC 7
BLOCK : NEUROBEHAVIOR AND SENSE SYSTEM
TOPIC : KUESIONER PRA SKRINING PERKEMBANGAN (KPSP)
DETEKSI DINI DAN TUMBUH

KEMBANG ANAK
DIVISI TUMBUH KEMBANG ANAK PEDIATRI SOSIAL

DEPARTEMEN ILMU KESEHATAN ANAK RSHS FK UNPAD
PERTUMBUHAN DAN
PERKEMBANGAN
Anak memiliki suatu ciri khas yaitu selalu

tumbuh dan berkembang sejak konsepsi
sampaiberakhirnya masa remaja
29
PERTUMBUHAN DAN
PERKEMBANGAN
• Pertumbuhan adalah bertambahnya ukuran dan
jumlah sel serta jaringan interselular, berarti
bertambahnya ukuran fisik dan struktur tubuh
sebagian atau keseluruhan, sehingga dapat
diukur dengan satuan panjang dan berat
• Perkembangan adalah bertambahnya struktur

dan fungsi tubuh yang lebih kompleks dalam
kemampuan gerak kasar, gerak halus, bicara dan
bahasa serta sosialisasi dan kemandirian
Ciri-ciri dan prinsip-prinsip

tumbuh kembang anak
1. Perkembangan menimbulkan perubahan
2. Pertumbuhan dan perkembangan pada tahap
awal menentukan perkembangan selanjutnya
3. Pertumbuhan dan perkembangan mempunyai
kecepatan yang berbeda.
4. Perkembangan berkorelasi dengan
pertumbuhan
5. Perkembangan mempunyai pola yang tetap
6. Perkembangan memiliki tahap yang berurutan
30
Prinsip - prinsip
• Perkembangan merupakan hasil proses
kematangan dan belajar
• Pola perkembangan dapat diramalkan
FAKTOR-FAKTOR YANG MEMPENGARUHI

TUMBUH KEMBANG
1. Faktor genetik
2. Faktor lingkungan
(biofisikopsikososial)
• Pranatal
• Perinatal
• Pascanatal
31
ASPEK-ASPEK Perkembangan yang
dipantau
• Gerak kasar atau motoriik kasar

• Gerak halus atau motorik halus
• Kemampuan bicara dan bahasa
• Sosialisasi dan kemandirian
Periode tumbuh kembang anak

• Masa Prenatal atau masa intra uterin ( masa
janin dalam kandungan)
32
1. Pranatal /Janin:
Masa zigot Masa

/ mudigah embrio
Masa janin
/ fetus
9
7 minggu pertama
janin belum bergerak
Denyut jantung ( + )
Usia 8 minggu janin

sudah berbentuk
manusia
BB 1 gram - PB 2,5 cm
10
33
Akhir Trimester ke 3
(36 mg) penambahan
ukuran meliputi subku
tan dan massa otot shg
janin dapat hidup
diluar
Aktivitas janin responsif

terhadap emosi ibu
11
12
34
Agar janin dalam kandungan tumbuh dan
berkembang menjadi anak sehat, Seorang ibu
diharapkan
Menjaga kesehatannya dengan baik
Selalu berada dalam lingkungan yang

menyenangkan
Mendapat nutrisi yang sehat untuk

janin yang dikandungnya
Memeriksakan kesehatannya secara teratur
Memberi stimulasi dini terhadap janin
Tidak mengalami kekurangan kasih sayang dari

suami dan keluarganya
Menghindari stre baik fisik maupun psikis
Tidak bekerja berat yang dapat membahayakan

kondisi kehamilannya
35
DECREASING PROPORTIONS
At birth, the head represents one-quarter of the neonate’s.
By adulthood, the head is only one-eighth the size of the body 15
Otak
✓Otak → Belum lengkap saat lahir.
✓Waktu lahir berat otak bayi → ¼ otak dws
(jumlah sel mencapai 2/3 sel otak dws)
Lahir berat pada saat di lahirkan : 350 gr

1,5 th : 1 kg
Dewasa : 1,5 kg
✓Tersusun oleh sel syaraf( neuron) dihubungkan → sinaps

Sinaps membentuk jalur kecil menciptakan semacam kabel
yang saling berhubungan di dalam otak.
16
36
KONSEP UMUM
Saat Lahir:
Berat otak anak
25% otak orang
dewasa
Saat usia 6 tahun:

Berat otak anak
Otak
95% otak orang LK
dewasa TB
Fisik Tubuh
Organ Reproduksi
KONSEP UMUM
Critical Period: The Concept

Experience-dependent synaptogenesis in critical periods
Bicara &
Melihat Bahasa
Mendenga Kecerdasan yang
r lebih kompleks
1000 HPK 2
tahun (Shonkoff, 2007)
37
KONSEP UMUM
95%
80%
HARUS TERMONITOR
25%
DENGAN BAIK
PERTUMBUHAN
SIRKUIT OTAK
Dalam
Kandungan
USIA ANAK
0 2 6
LAHIR TAHUN TAHUN
40 Minggu 24 Bulan
[x 7 hari] [x 30 hari]
280 hari 720 hari
1000 HARI PERTAMA
✓Jumlah dan pengaturan hubungan →

mulai dari kemampuan belajar, berjalan,
mengenal huruf, hingga bersosialisasi.
✓Setelah lahir, perkembangan otak berlanjut →
bertambah di antara neuron.
✓ Pada usia 10 tahun anak mempunyai100- 500 triliun

sinaps sama dengan dewasa
20
38
Human Brain
at Birth 6 Years Old 14 Years Old
21
● 3 tahun pertama →
pembentukan
jaringan otak yang
dominan
● 3-10 tahun proses

seimbang
● > 10 tahun →
pruning sel-sel
otak, sinap dan
dendrit yang tidak
diperlukan →
network yang
ramping dan
efisien pada usia
dewasa
22
39
23
2. Masa bayi (INFANCY) UMUR 0

SAMPAI 11 bulan
• Masa neonatal dini, umur 0-7 hari
• Masa neonatal lanjut, umur 8-28 hari
• Masa post (pasca) neonatal, umur 29 hari
sampai 11 hari
3. MASA ANAK DIBAWAH 5 TAHUN
(ANAK BALITA, UMUR 12-59 BULAN)
4. MASA ANAK PRASEKOLAH (ANAK
UMUR 60-72 BULAN)
40
MILESTONES
OF MOTOR
DEVELOPMENT
41
Umur 3 – 6 bulan
• Berbalik dari telungkup ke terlentang

• Mengangkat kepala setinggi 90º
• Mempertahankan kepala dalam posisi tegak dan
stabil
• Memegang tangannyas sendiri
• Berusaha memperluas pandangan
• Mengarahkan matanya pada benda benda kecil
Umur 6-9 bulan
• Duduk (sikap tripoid-sendiri)

• Belajar sendiri, kedua kakinya menyangga
sebagian berat badan
• Merangkak meraih maianan atau mendekati
seseorang
• Bersuara tanpa arti mamama, dada…dada
• Mencari mainan/ benda yang dijatuhkan
42
Umur :9 bulan
Bayi dapat duduk dengan

kepala tegak secara
bebas selama 1 menit
dan dapat menahan
keseimbangan badannya.
Mengambil benda yang
menarik perhatiannya.
Umur : 18 bulan
Dapat naik kursi tanpa

pertolongan, berjalan
menuruni anak tangga,
berdiri dengan baik walau
sambil membawa mainan.
43
Umur : 2 tahun
Dapat membedakan mainan : kubus,

mobil-mobilan, alat perlengkapan makan-
minum dari plastik.
Umur : 3-4 tahun
Anak dapat disuruh membuat gambar :

garis, lingkaran sesuai contoh yang
diberikan.
44
Umur : 5 tahun
Dapat bergabung bermain bersama teman-

teman seusianya, diajarkan untuk tidak
bertengkar, diajarkan untuk bersikap
sportif.
GANGGUAN TUMBUH-KEMBANG
YANG SERING DITEMUKAN
1. Gangguan bicara dan bahasa
2. Cerebral palsy
3. Sindrom Down
4. Perawakan Pendek
5. Gangguan Autism
6. Retradarsi Mental
7. Gangguan Pemusatan, Perhatian dan
Hiperaktivitas (GPPH)
45
Stimulasi tumbuh kembang balita dan
anak prasekolah
Setiap anak perlu mendapatkan stimulasi sedini
mungkin dan terus menerus
Dapat dilakukan oleh ayah, ibu dan orang-orang

terdekat
Kurang stimulasi menyebabkan penyimpanan

tumbuh kembang anak bahkan gangguan menetap
KELOMPOK UMUR STIMULASI ANAK

No PERIODE TUMBUH KEMBANG KELOMPOK UMUR STIMULASI
1 Masa Prenatal , janin dalam kandungan Masa prenatal
2 Masa bayi 0-12 bulan Umur 0-3 bulan
Umur 3-6 bulan
Umur 6-9 bulan
Umur 9-12 bulan
3 Masa anak balita 12 – 60 bulan Umur 12-15 bulan
Umur 15-18 bulan
Umur 18-24 bulan
Umur 24-36 bulan
Umur 36-48 bulan
Umur 48-60 bulan
4 Masa prasekolah 60-72 bulan Umur 60-72 bulan
46
DETEKSI DINI TUMBUH
KEMBANG ANAK
• Deteksi dini tumbuh kembang anak adalah
kegiatan/pemeriksaan untuk menemukan secara dini
adanya penyimpangan tumbuh kembang pada balita dan
anak prasekolah.
• Ada 3 jenis deteksi dini tumbuh kembang yang dapat
dikerjakan oleh tenaga kesehatan di tingkat puskesmas dan
jaringannya, berupa:
– Deteksi dini penyimpangan pertumbuhan
– Deteksi dini penyimpangan perkembangan
– Deteksi dini penyimpangan mental emosional
Kuesioner Pra Skrining Perkembangan (KPSP)
• Tujuan untuk mengetahui perkembangan anak normal atau

ada penyimpangan.
• Jadwal skrining/pemeriksaan KPSP rutin adalah pada umur
3, 6, 9, 12, 15, 18, 21, 24, 30, 36, 42, 48, 54, 60, 66 dan 72
bulan.
• Jika anak belum mencapai umur skrining tersebut, minta ibu
datang kembali pada umur skrining yang terdekat untuk
pemeriksaan rutin.
• Apabila orang tua datang dengan keluhan anaknya
mempunyai masalah tumbuh kembang, sedangkan umur
anak bukan umur skrining maka pemeriksaan menggunakan
KPSP untuk umur skrining terdekat - yang lebih muda.
47
• Alat/instrumen yang
digunakan adalah:
– Formulir KPSP menurut umur.
Formulir ini berisi 9 – 10
pertanyaan tentang
kemampuan perkembangan
yang telah dicapai anak.
– Sasaran KPSP anak umur 0-72
bulan.
– Alat bantu pemeriksaan
berupa:
• Pensil, kertas, bola sebesar bola
tenis, kerincingan, kubus
berukuran sisi 2,5 Cm sebanyak 6
buah, kismis, kacang tanah,
potongan biskuit kecil berukuran
0.5 - 1 cm.
48
49
Interpretasi hasil KPSP
• Hitunglah berapa jumlah jawaban Ya.
• Jawaban Ya, bila ibu/pengasuh anak menjawab: anak bisa atau
pernah atau sering atau kadang-kadang melakukannya.
• Jawaban Tidak, bila ibu/pengasuh anak menjawab: anak belum
pernah melakukan atau tidak pernah atau ibu/pengasuh anak tidak
tahu.
– Jumlah jawaban ‘Ya’ = 9 atau 10, perkembangan anak sesuai dengan
tahap perkembangannya (S).
– Jumlah jawaban ‘Ya’ = 7 atau 8, perkembangan anak meragukan (M).
– Jumlah jawaban ‘Ya’ = 6 atau kurang, kemungkinan ada penyimpangan
(P).
• Untuk jawaban ‘Tidak’, perlu dirinci jumlah jawaban ‘Tidak’ menurut
jenis keterlambatan (gerak kasar, gerak halus, bicara dan bahasa,
sosialisasi dan kemandirian).
50
KASUS – 1
• Usia anak: 6 bulan 10 hari

• Keluhan ibu:
Tidak ada keluhan
Ibu merasa anaknya sehat dan
normal saja
Hasil KPSP usia 6 bulan:

• Jumlah “Tidak”: 1
• Kesan : SESUAI
10
3
KASUS – 2
• Usia anak: 2 tahun 1 bulan

• Keluhan ibu:
Anak belum bisa bicara
Anak sangat aktif

• Jumlah “Ya”: 5
• Kesan : PENYIMPANGAN
51
KASUS – 3
Anak usia 24 bulan datang

dengan keluhan
hanya bisa mengucapkan
mama dan papa spesifik

• Jumlah “Ya”: 7
• Kesan : MERAGUKAN
52
Intervensi
Bila perkembangan anak sesuai (S), lakukan tindakan berikut:
• Beri pujian kepada ibu
• Teruskan pola asuh anak sesuai dengan tahap
perkembangan anak.
• Beri stimulasi perkembangan anak setiap saat, sesering
mungkin, sesuai dengan umur dan kesiapan anak.
• Ikutkan anak pada kegiatan penimbangan dan pelayanan
kesehatan di posyandu secara teratur sebulan 1 kali dan
setiap ada kegiatan Bina Keluarga Balita (BKB).
• Lakukan pemeriksaan/skrining rutin menggunakan KPSP
setiap 3 bulan pada anak berumur kurang dari 24 bulan
dan setiap 6 bulan pada anak umur 24 sampai 72 bulan.
Bila perkembangan anak meragukan (M),

lakukan tindakan berikut:
• Beri petunjuk pada ibu agar melakukan
stimulasi perkembangan pada anak lebih
sering lagi, setiap saat dan sesering mungkin.
• Ajarkan ibu cara melakukan intervensi
stimulasi perkembangan anak untuk
mengatasi penyimpangan/mengejar
ketertinggalannya.
• Lakukan pemeriksaan kesehatan untuk
mencari kemungkinan adanya penyakit yang
menyebabkan penyimpangan
perkembangannya.
53
Intervensi
Bila tahapan perkembangan terjadi penyimpangan (P),

lakukan tindakan berikut:
• Rujuk ke Rumah Sakit dengan menuliskan jenis dan

jumlah penyimpangan perkembangan (gerak kasar, gerak
halus, bicara & bahasa, sosialisasi dan kemandirian).
54
Daftar Tilik Pemeriksaan KPSP
PENILAIAN
0 1 2 3 Total Nilai
PERSIAPAN
Apa saja persiapan yang harus dilakukan sebelum melakukan
pemeriksaan KPSP
1. Persiapan formulir 0,5
2. Persiapan alat bantu pemeriksaan 0,5
PELAKSANAAN
3. Sapa orangtua/pengasuh dan anak dengan ramah 1
4. Menjelaskan kepada orangtua/pengasuh tujuan dilakukan
pemeriksaan KPSP 3
5. Tentukan usia kronologis anak dengan menanyakan tanggal bulan
dan tahun anak lahir 3
6. Pilih formulir KPSP yang sesuai dengan usia anak 3
7. Lakukan pemeriksaan dengan mengikuti intruksi sesuai formulir satu

per satu secara berurutan, catat hasil dari setiap pertanyaan dan
hitung jumlah jawaban "ya" dan "tidak" dari 10 pertanyaan tersebut 3
MENGAMBIL KESIMPULAN
8. Menyimpulkan dan menjelaskan hasil pemeriksaan 2
9. Menentukan tindakan yang akan dilakukan 2
10. Edukasi pada orangtua dan mengucapkan terimkasih dan salam
perpisahan 2
Nilai total : 20
55
TOPIC 8
TOPIC : BASIC HEARING EXAMINATION
BASIC HEARING EXAMINATION, VESTIBULAR EVALUATION AND AUDIOGRAM INTERPRERTATION
NEUROBEHAVIOR AND SPECIAL SENSES (NBSS) SYSTEM
Introduction
Hearing loss and vestibular disorders can occur at any age, ranging from infancy to old age. They
affect the quality of life. Basic hearing examinations such as the tuning fork test and voice test, also
the Romberg and gait test are easily practiced even in remote areas and very useful to detect
hearing loss and vestibular disorders. Although not precise but may help in giving a rough guide
about the patients condition.
Usage of an audiology device needs special training and practice, though students still can learn the
basic audiogram interpretation.
This learning guide includes:
• Tuning fork test.
• Voice test.
• Pure Tone Audiogram interpretation.
• Gait test.
• Romberg test.
Knowledge
After following the exercise, the students should be able to describe:
• Anatomy and physiology of the ear.

• Mechanism of hearing, describing the conduction and sensorineural component.
• Basic hearing examination using the tuning fork and voice test.
• Basic pure tone audiogram interpretation.
• Basic vestibular examination through gait and romberg test.
Skills
• Tuning fork examination.

• Voice test examination.
• Interpret the result of pure tone audiometry.
• Gait test.
• Romberg test.
56
Method
a. Presentation.
b. Demonstration.
c. Exercise.
d. Independent exercise in standardized patient.
Evaluation
Equipment
- Presentation: audiovisual.
- Demonstration and exercise: tuning fork and audiogram chart.
Communication skills
Students should be able to communicate to explain the examination procedure to assure the
patients cooperativeness during examination.
Management skills
Students should be able to develop an appropriate evaluation report from each examination with
each ears described separately, because this report will have an effect on further decision making
for this patient.
Attitudes and Professional behavior:
Students should be able to:
• Appreciate patients preferences such as receiving an explanation on his/her condition.

• Make an appropriate referral to an otorhinolaryngologist for further management in complicated
cases.
57
Basic hearing examination procedure: tuning fork and voice test
TUNING FORK TEST
• To differentiate conductive or sensorineural hearing loss.

• Tuning forked used are the 512 Hz or 256 Hz.
• Among other tuning fork tests, the Rinne and Weber’s tuning fork test are the mostly used.
▪ Rinne test :
- Hold the tuning fork with one hand.
- Vibrate and place it on the mastoid bone on one side until the patient can not hear the
sound.
- Move it in front of the external ear (external auditory canal) and ask the patient whether
he/she still can hear the sound.
- Perform the same procedure on the opposite site.
Rinne test
Rinne Test Interpretation:
• Rinne positive: patient still can hear sound when the tuning fork is placed in front of the external auditory canal.
• Rinne negative: patient can not hear sound when the tuning fork is placed in front of the external auditory auditory canal.
58
▪ Weber Test:
- Hold the tuning fork with one hand.
- Vibrate the tuning fork.
- Place it in the center of the forehead.
- Ask the patient to indicate that he/she can hear the sound louder at the right side or the
left side or he/she can hear the same loudness on both ears.
Weber test
59
60
VOICE TEST
This picture shows a voice test being

performed, the examiner in the left of
1 mtr→ the picture while the patient on the

right with the distance only one meter
from
one another. Note that one of the ears

of the patient is being masked by a
Barany noise box device.
Principles:
▪ A basic examination to roughly predict a level of hearing loss.

▪ Hearing examination is performed with the distance between the examiner and the patient just
1 (one) meter apart, done in a sound-proof room. With the patient sitting sideways in front of
the examiner, so that the tested ear will face the examiner. This position is to prevent lip
movement reading by the patient, because most deaf patients are experts at reading lip
movements.
▪ Each ear is examined one at a time, the untested ear is given a masking voice such as produced
by a barany noise box device, otherwise a noisy ticking wrist watch will suffice. Just place the
wrist watch by pressing against the non-test ear.
▪ Masking on the non test ear is crucial to prevent cross hearing.
61
Picture of various types of tuning forks and a Barany Noise Box
Hearing Interpretation:
• Normal ( 0-25 dB): Hears whisper.

• Mild hearing loss (26-40 dB): Able to hear and repeat words produced with a loudness of a
normal communication voice.
• Moderate hearing loss (41-60 dB): Able to hear and repeat words produced with a loud
voice.
• Severe hearing loss (61-80 dB): Able to hear and repeat words shouted near the ear.
• Profound hearing loss (> 80 dB): Not able to hear and repeat words shouted near the ear.
AUDIOMETRY
- Is a hearing assessment using pure tone audiometer with test results written into a graphic that
is named an audiogram.
- Written in the audiogram are two hearing components: the air conduction and bone
conduction, both written with specific symbols to differentiate each component and in different
colours to specifiy right from left ear.
- Symbols used in an audiogram:
▪ Results for the left ear is written in blue and right ear in red.
▪ Non masking symbols for air conduction
o “X” for left ear
o “O” for right ear
▪ Non masking symbols for bone conduction
o “<” for right ear
o “>” for left ear
62
- Interpretation of audiogram.
▪ Hearing depends on the integrity of the air conduction component, the level of hearing will
be measured from this component.
▪ Level of hearing for each air conduction components: counted by the adding each decibel-
results on each communication freq as at 500, 1000, 2000 and 4000 Hz, finally the total sum
is divided in 4, the result will be the mean-level of hearing for each air conduction
component.
▪ Compare the equation result with the hearing loss chart, define the patients level of hearing
loss of each ear.
▪ Define the type of hearing loss; conductive, sensorineural, or mixed (will be discussed
below).
▪ Lastly, write the interpretation, that consists of the degree of hearing followed by the type of
hearing loss, example: moderate sensorineural hearing loss, severe mixed hearing loss, etc.
This audiogram is written only the symbols of the air conduction,
note how the symbols differentiate left from right ear
Types of Hearing Loss
1. Conductive hearing Loss

Principles of interpretation:
• BC tresholds within normal limit.

• AC tresholds beyond the normal hearing range (greater than 25 dB).
63
2. Sensorineural hearing loss
▪ Both BC and AC are not within the normal hearing range (> 25 dB).
▪ Gap between the BC and AC < or = 10 dB, or both components are in one line.
3. Mixed Hearing Loss

▪ Both BC and AC components are not within the normal hearing range.
▪ Air-bone gap between both components more than 10 dB.
64
65
VESTIBULAR EXAMINATION
Vestibular disorders can exist as a complication of the ear disease. It influences the coordination system.
Romberg Test
1. Patient stands forward with the feet in a line, the heels and toes are touching. Both hands in a cross position on the chest.
2. The examiner’s stands at the side of the patient to watch if the patient falls in this test.
3. The patient is asked to close the eyes and the examiner notice the direction of the fall of the
patient.
4. Normal response is the patient should be able to maintain posture without movement of the
feet.
The Tandem Gait Test
1. The patient is asked to walk toward the examiner with one foot placed in front of the other
and the heel touching the toes at each step.
2. Normal response is the patient moves without any unsteadiness or sudden lateral placement
of one foot to maintain balance.
66
LEARNING GUIDE
Basic Hearing and Vestibular Examination
PERFORMANCE SCALE
NO STEP
0 1 2
Preparation – Client assessment

1 Greet the patient respectfully and with kindness, introduce
yourself.
2 Politely ask patient identification: name, age, education,

occupation, and address.
3 Ask the patient which ear has the hearing difficulty and whether
he/she has vestibular complains.
4 Wash your hands first with antiseptic soap and dry it with paper
tissues or towel, wear the mask and hand gloves.
5 With a headlight examine each outer ear canal to make sure no

cerumen, otherwise it will effect the hearing examination result.
This is done by holding the ear: the middle finger and the thumb
gently pulls the pinna outwards-upwards and the index finger
pushes the tragus forward, this is to straighten the outer ear canal
to assure the examiners view is not blocked by the canal curve.
6 Give a brief and adequate explanation about the examination.
Rinne Test
7 Hold the tuning fork with one hand.
8 Vibrate and place it on the mastoid bone on one side until the
patient can not hear the sound.
9 Move it in front of the external ear.
10 Ask the patient whether he/she still hears the sound or not.
11 Perform the same procedur on the opposite side.
Weber Test
67
12 Hold the tuning fork with one hand.
13 Vibrate the tuning fork.
14 Place it in the center of the forehead.
15 Ask the patient to indicate on which side that he/she can hear
most or hears the sound symmetric on both ears.
Voice test
16 Hearing examination is performed with the distance between the
examiner and the patient just 1 (one) meter apart, done in a
sound-proof room. With the patient sitting sideways in front of the
examiner, so that the tested ear will face the examiner.
17 Each ear is examined one at a time, the untested ear is given a

masking voice such as produced by a barany noise box device,
otherwise a noisy ticking wrist watch will suffice. Just place the
wrist watch by pressing against the non-test ear to prevent cross-
hearing.
18 Patient been told to repeat the word which whispered or said by

the examiner. The examiner uses different voice loudness to
examine the patients hearing, starting with the whispering voice
and then raised in loudness until the patients responds, the
hearing level is based on the patients respond to examiner voice.
19 Decide the hearing intensity.
Normal, mild, moderate, severe or profound hearing loss.
20 Adjust the patients sitting position to examine the other ear in the
same manner.
Audiogram interpretation
21 Start by paying attention to the audiogram chart, define which
chart represents the right and left ear.
22 Decide the degree of hearing loss for each ear.
Start by counting the air conduction by adding the decibles
reached in each conversation frequency, the sum is divided by
4. Begin with the air conduction component pay attention on
each 500, 1000, 2000, and 4000 Hz frequency column, note
the results of decibels marked on each column and add all the
decibel results.
Degree of Hearing Loss
68
0 to 25 dBHL → within normal limits
26 to 40 dBHL → mild loss
41 to 60 dBHL → moderate loss
61 to 80 dBHL → severe loss
More 80 dBHL → very severe loss (profound loss)
23 Observe the distance between the bone and air conduction
24 Define the type of hearing loss in each ear separately.

Type of hearing loss
• Both component less than 25 dB or in normal area: normal

hearing
• Both components sum greater than 25 dB and air bone gap <
10 dB: sensorineural hearing loss.
• Bone conduction less than 25, while air conduction greater
than 25 dB and air bone gap >10 dB: Conductive hearing loss.
• Both components greater than 25 dB and air bone gap > 10 dB
with: mixed type hearing loss.
25 Make a report of the examination result, each examination
describes the left and right ear separately to aid for further
examination.
Romberg Test
26 Patient stands forward with the feet in a line, the heels and toes are touching. Both hands in a
cross position on the chest.
27 The examiner’s stands at the side of the patient to watch if the patient falls in this test.
28 The patient is asked to close the eyes and the examiner notice the direction of the fall of the
patient.
29 Normal response is the patient should be able to maintain posture without movement of the
feet.
The Tandem Gait Test
30 The patient is asked to walk toward the examiner with one foot
placed in front of the other and the heel touching the toes at each
step.
31 Normal response is the patient moves without any unsteadiness or

sudden lateral placement of one foot to maintain balance.
69
32 Give the general result about the patient’s hearing and balance.
CRITERIA OF PERSONAL PERFORMACE EVALUATION
Scale Performace Achievement
0 If student doesn’t perform the task
1 If student performs the task incorrectly/incompletely
2 If student performs the task correctly and completely
70
Audiogram Interpretation Exercises:
71
72
73
74
75
TOPIC 8
TOPIC : EXTERNAL EYE EXAMINATION AND DIRECT FUNDUSCOPY
Eye Examination Learning Guide
Procedure
Distance Visual Acuity Testing
1. Place the patient at the designated distance, usually 6 metres, from

a well-illuminated Snellen chart. If glasses are normally worn for
distance vision, take it off, to measure uncorrected visual acuity.
2. By convention, the right eye is tested and recorded first.

Completely occlude the left eye using the palm of your hand or an
opaque occluder.
(Be sure that your palm is not pressing, nor the occluder is not
touching against the eye. Observe the patient during the test to
make sure there is no concious or inadvertent peeking.)
3. Start with the largest optotypes available on the chart. Ask the
patient to say aloud each letter or number, or name the picture
object on the lines of succesively smaller optotypes, from left to
right or, alternatively, as you point to each character in any order,
until the patient correctly identifies at least one half of the
optotypes on a line.
Note: the corresponding acuity measurement shown at that line of the

chart. Record the acuity value for each eye separately, as illustrated below.
Record the acuity measurement as a notation (e.g. 6/6) in which the
numerator represents the distance at which the test is performed and the
denominator represents the numeric designation for the line read. If the
patient misses half or fewer than half the letters on the smallest readable
line, record how many letters were missed; for example, 6/12-². If the
patient misses more than half the letters on the smallest readable line,
record how many letters could be read, and tag it to the previous larger
line; for example, 6/12⁺². If acuity is worse than 6/6, recheck with a
pinhole.
76
4. Repeat steps 1 through 3 for the left eye, with the right eye
covered.
If the patient cannot see the largest Snellen letters, proceed as follows:
1. Display two or more fingers of one hand and ask the patient to
count the number of fingers displayed.
Start at a distance of 1 meter, and step back further every 1 meter.
Record the longest distance at which counting is done accurately;

for example, 2/60 means that patient could count the number of
fingers for as far as 2 meter.
(the procedure is done if the patient is unable to resolve the largest

optotypes on the chart from a distance of 6 meter)
If the patient cannot count fingers at a distance of 1

meter:
2. Display a hand movement as gentle waving motion in vertical and

horizontal direction.
Determine whether or not he or she can detect the movement and
mention the direction of your hand's motion.
Record the response as hand motion (HM) or 1/300.
No record of distance is required.
If the patient cannot detect your hand motion:
3. Shine a torchlight toward the patient's eye from approximately 30-

40 cm and turn it on and off (or move aside) to determine if light
perception is present.
- Record the response as LP (light perception) if the patient can
see the light,
No record of distance is required.
- Record the response as NLP (no light perception) if the patient

cannot see even the brightest light.
4. If light is perceived from straight ahead,

Move the light sequentially into each of the four quadrants of the
visual field (i.e. above, below, left, right).
77
Turn the torchlight on and off in each field, and ask if the patient
can see the light.
5. If the patient correctly identifies the direction from which the light
is coming, record the response as LP with projection. Specify the
quadrant(s) in which light projection is present.
6. If the patient is unable to identify any direction but is able to
discern light in the straight-ahead position, record the response as
LP without projection.
Pinhole Visual Acuity Testing
1. Position the patient and occlude the eye not being tested, as done
for the distance acuity test
2. Place the pinhole in front of the eye that is to be tested, and

instruct the patient to look at the distance chart through the
pinhole
3. Ask the patient to begin to read the line with the smallest letter
that are legible as determined on the previous vision test without
the use of the pinhole
4. Record the Snellen acuity obtained and procede or follow it with

the abbreviation 'PH'; for example 6/12 PH 6/6
5. Repeat steps 1 through 4 for the left eye
Reference:
Wilson, FM. Practical Ophthalmology: A Manual for Beginning Residents. 4th Edition. American
Academy of Ophthalmology.
78
TOPIC :9
MENTAL STATUS EXAMINATION GUIDELINE
IV MENTAL EXAMINATION
Appearance
Personal identification (Observation)
Behavior and psychomotor activity (Observation)
General description (Observation)
Speech
(Observation)
Emotion
Mood
How is your mood lately?
Unhappy
Do you feel depressed? irritated? worried, nervous, or anxious?
Happy
Do you feel excited?
Affect
Define the outward expression of the patient by observing facial expression and behavior
Thinking
Form of thinking (observation)
Productivity, continuity of thought, language impairments
79
Content of thinking
Obsessions or plans about suicide
Have you had any thoughts about hurting yourself, wishing that you were dead, or ending your life?
Thought disturbances
Now, I will ask about several unusual experiences but can be experienced by some people
Delusion
Delusion of persecution
Does anyone ever spy on you or plot against you?
Delusion of reference
Did it ever seem that people were talking about you or taking special notice of you?
Delusion of grandeur
Do you have excellent talents or abilities that other people don’t have?
Delusion of self accusation
Do you bothered by guilt feeling about something you may have done in the past that deserve
punishment?
Somatic delusion
Is there any problem with your physical health which the doctors cannot explained?
Delusion of control
• Thought withdrawal
Are your thoughts ever taken out of your head ?
• Thought insertion
Are thoughts that were not your own ever put into your head ?
• Thought broadcasting
Do you sometimes feel as if your thoughts were being broadcast out loud so that other people could
actually hear what you were thinking?
• Thought control
Do you sometimes feel that someone or something outside yourself controls your thoughts or
action against your will?
80
Perceptual disturbances
Auditory hallucination
Do you sometimes hear things that others don’t hear?
→ What kind of voice do you hear?
Is it whispering or talking ?
How many voices do you hear?
➔ If more than one voice: Do they talk to one another?

Does the voice comment to what you do or what you think?
Visual hallucination
Do you sometimes have “visions” or see things that others don’t see?
Olfactory hallucination
Do you sometimes smell things that are unusual or that others don’t smell?
Gustatory hallucination
Do you sometimes taste things that are unusual?
Tactile hallucination
Do you sometimes feel any strange or unusual sensation in your skin?
Sensorium and Cognition
Consciousness (observasi)
Now I will ask about several specific things which are part of the examination
Orientation
Time
Can you tell me what is today’s date? (the day, month, year)
If the answer is not correct :
Do you think that right now is morning, afternoon, or night?
Place
What is the name of the place that we are in now?
Person
81
Do you know who is …………….…… ?
Concentration and calculation
I will examine your concentration ability
Calculate 100 - 7? Substracted by 7? Substracted by 7? Substracted by 7? Substracted by 7?
Memory
Immediate memory
Now I will examine your memory.
I will mention five numbers. Please repeat them after I have mentioned them (for example: 1,4,9,2,5)
Recent memory
How did you come to this place?
Remote memory
Where do you live when you were a kid?
Abstract thinking
I will ask about the synonym and the meaning of the proverbs.
What is the meaning of …………….?
Judgment
Social judgment
In your opinion, What should you do if ……. ? (question is adjusted to patient's experience)
Test judgment
What would you do with a stamped, addressed letter found in the street?
Insight
Do you think that you have mental problem?
V CLOSING
Thank the patient for providing the information
Explain to the patient about:
- Diagnosis (explanation should be adjusted to the patient's condition)
- Treatment plan (includes: types, benefit, dose (for psychopharmacological treatment), the possible
82
side effects, and how to handle it)
Give time to the patient to ask questions
Make a schedule for the next meeting or provide referral to psychiatrist
TOPIC : 10
PSYCHIATRIC EXAMINATION GUIDELINE
SKILL LABORATORY OF FACULTY OF MEDICINE UNPAD

I INTRODUCTION
Greeting the patient and relatives
Good (morning/afternoon/evening/night)
Introducing the examiner’s self
Explain the aim of the interview
I will examine you to identify your complaints or problems so I can help you to overcome your
complaints or to find out the solutions for your problems
Confidentiality
All information that you will tell me is confidential. It will be broken only in some specific situations,
such as you intend to harm yourself or others
Informed consent
Do you agree?
II PATIENT’S IDENTITY
Before we start, I need information about your socio-demographic characteristics
(Ask name, age, last education, marital status, occupation, patient's current living circumstances,
religion)
III HISTORY OF ILLNESS
83
CHIEF COMPLAINT
How can I help you?
HISTORY OF PRESENT ILLNESS
Onset
Since when this things happened?
THE COURSE OF ILLNESS
(Explain the course of the illness chronologically)
The precipitating factor
Was there any special event which bothering you before all these things happened?
THE COURSE OF ILLNESS
Emotional changes
Is there any changes in your mood?
Behaviour changes
Is there any changes in your behaviour?
Cognitive symptoms
Do you have any problem with concentration or thinking ability?
Vegetative symptoms
Is there any changes in your sleep or appetite or urination or defecation or sexual function?
Somatic symptoms
Do you have any physical complains?
Have you experienced headache, fever, seizure, or decrease of consciousness?
Daily functioning
Do you still doing your tasks as usual?
Do you have any problem with personal hygiene?
How involved are you with the social life around you?
84
THE USE OF MEDICATION AND SUBSTANCE ABUSE
Right before all these things happened, did you use medication for certain ilness or complains? Did you
drink alcohol or use illegal drugs?
HISTORY OF PAST ILLNESS
Psychiatric disorders
Have you had mental emotional problems before?
Physical problems
Have you suffered from severe disease?
FAMILY HISTORY
Does the family have a history of mental emotional problems, substance abuse or antisocial behavior?
How is the role each person played in the patient's upbringing?
How is this person's current relationship with the patient?
How is the support and family's attitude towards the mental emotional problems suffered by the their
relative?
Psychosocial History
Is there any mental emotional problems suffered by the patient in childhood, adolescent, and young
adulthood?
85

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STUDENT HANDBOOK

SECOND YEAR OF UNDERGRADUATE

TOPIC 1: INTRODUCTION, MOTORIC, AND SENSORIC EXAMINATION ………

SKILL LABORATORY PRACTICE MODULE

BLOCK : NEUROBEHAVIOR AND SPECIAL SENSE SYSTEM

TOPIC : INTRODUCTION, MOTORIC, AND SENSORIC EXAMINATION

1 Greet the patient and introduce the examiner’s self,

2 Ask the patient’s identity

- The patient’s name

- The patient’s age

- The patient’s work

- The patient’s residence

1 Ask the patient why she/he come to clinic

2 Ask the date of onset

- Whether the onset was sudden or insidious

- Whether the patient was unconsciousness, fever,

- The precipitating or risk factors

- The course of illness

III GENERAL EXAMINATION

1 - Assess the patient’s level of consciousness, blood

2 - Assess the cardiac and pulmonary condition

1 Cranial nerve examination

Level of strength, tonicity (spasticity, rigidity),

3 Sensory function examination.

- Exteroception sensory function.

- Bladder and bowel function.(vegetative function)

- Aphasia (motor and sensory aphasia)

1 The lumbar punction examination test

3 Electroencephalography (EEG) examination

4 Electromyography (EMG) examination

5 Laboratory Finding examination

2. The examiner inspect the motor condition of

3. The contour and muscle development of the two

4. During this inspection also detect the muscle

The strength of limbs.

5. The patient is asked to elevate and contract of

Grade 5. The patient can against the full

Grade 4. The patient can against only light

Grade 3. The patient can only against the

Grade 2. The patient can only move the limbs

Grade 1. The patient cannot move the limbs but

Grade 0. The patient is total paralysis

7. The same manner for examining the lower

The tone of muscles

9. The examiner flex and extend passively the

Abnormal response is the increased of tonicity of

Comparing the tone’s limb muscles of two side

10. The examiner percuss on one area of limbs.

(Fasciculation is the contraction of some group of

Tests of sensory function are concerned with

The sensory function is include exteroception

Exteroception sensory examinations.

The patient sits or lies with hand supinated, and

The examiner takes a wisp of cotton and applies it

The cotton is applied to the skin of the neck

Sensation in the lower limb is examined in a similar

2 Pain and temperature sensation tests are

Pain sensation is tested with pinwheel or needle.

Temperature sensation is tested with glass tube

Position sense is tested by gently moving a

The patient is asked to close the eyes

The examiner grasps the terminal phalanx in the

The patient is asked to indicate whether the digit is