STATUS UJIAN

KEPANITERAAN KLINIK SENIOR

ILMU PENYAKIT SARAF (NEUROLOGI)

BAGIAN / DEPARTEMEN ILMU PENYAKIT SARAF (NEUROLOGI)

FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA / RSMH

PALEMBANG

NAMA : ...............................................................

NIM : ...............................................................

SEMESTER : ...............................................................

TANGGAL : ...............................................................

PENGUJI : ...............................................................

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STATUS PENDERITA NEUROLOGI

IDENTIFIKASI

Nama : .................................................................................

Umur : .................................................................................

Jenis Kelamin : .................................................................................

Alamat : .................................................................................

Agama : .................................................................................

MRS Tanggal : .................................................................................

ANAMNESA (Auto / Allo Anamnesa)

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PEMERIKSAAN

STATUS PRESENS

Status Internus

Kesadaran : ....................................

Gizi : ....................................

Suhu Badan : ....................................

Nadi : ....................................

Pernapasan : ....................................

Tekanan Darah : ....................................

Berat Badan : ....................................

Tinggi Badan : ....................................

GCS = ........... (E: …., M: ....., V: .......)

Jantung : ....................................

Paru-paru : ....................................

Hepar : ....................................

Lien : ....................................

Anggota Gerak: ....................................

Genitalia : ....................................

Status Psikiatrikus

Sikap : ....................................

Perhatian : ....................................

Ekspresi Muka: ....................................

Kontak Psikik: ....................................

Status Neurologikus

KEPALA

Bentuk : ....................................

Ukuran : ....................................

Simetris : ....................................

Hematom : ....................................

Tumor : ....................................

Deformitas : ....................................

Fraktur : ....................................

Nyeri fraktur : ....................................

Pembuluh darah: ....................................

Pulsasi : ...................................

LEHER

Sikap : ....................................

Torticolis : ....................................

Kaku kuduk : ....................................

Deformitas : ....................................

Tumor : ....................................

Pembuluh darah : ....................................

SYARAF-SYARAF OTAK

N. Olfaktorius Kanan Kiri

Penciuman .................................... ....................................

Anosmia .................................... ....................................

Hyposmia .................................... ....................................

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Kanan Kiri

Parosmia .................................... ....................................

N.Opticus

Visus .................................... ....................................

Campus visi V.O.D V.O.S

- Anopsia .................................... ....................................

- Hemianopsia .................................... ....................................

Fundus Oculi

- Papil edema .................................... ....................................

- Papil atrofi .................................... ....................................

- Perdarahan retina .................................... ....................................

Nn. Occulomotorius, Trochlearis dan Abducens

Kanan Kiri

Diplopia .................................... ....................................

Celah mata .................................... ....................................

Ptosis .................................... ....................................

Sikap bola mata

- Strabismus .................................... ....................................

- Exophtalmus .................................... ....................................

- Enophtalmus .................................... ....................................

- Deviation conjugae .................................... ....................................

Gerakan bola mata .................................... ....................................

Pupil

- Bentuknya .................................... ....................................

- Besanya .................................... ....................................

- Isokori/anisokor .................................... ....................................

- Midriasis/miosis .................................... ....................................

- Refleks cahaya

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Kanan Kiri

- Langsung .................................... ....................................

- Konsensuil .................................... ....................................

- Akomodasi .................................... ....................................

- Argyl Robertson .................................... ....................................

N.Trigeminus

Kanan Kiri

Motorik

- Menggigit .................................... ....................................

- Trismus .................................... ....................................

- Refleks kornea .................................... ....................................

Sensorik

- Dahi .................................... ....................................

- Pipi .................................... ....................................

- Dagu .................................... ....................................

N.Facialis Kanan Kiri

Motorik

Mengerutkan dahi .................................... ....................................

Menutup mata .................................... ....................................

Menunjukkan gigi .................................... ....................................

Lipatan nasolabialis .................................... ....................................

Bentuk Muka

- Istirahat .................................... ....................................

- Berbicara/bersiul .................................... ....................................

Sensorik

2/3 depan lidah .................................... ....................................

Otonom

- Salivasi .................................... ....................................

- Lakrimasi .................................... ....................................

- Chovstek’s sign .................................... ....................................

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N. Statoacusticus

N. Cochlearis Kanan Kiri

Suara bisikan .................................... ....................................

Detik arloji .................................... ....................................

Tes Weber .................................... ....................................

Tes Rinne .................................... ....................................

N. Vestibularis

Nistagmus .................................... ....................................

Vertigo .................................... ....................................

N. Glossopharingeus dan N. Vagus

Arcus pharingeus ....................................

Uvula ....................................

Gangguan menelan ....................................

Suara serak/sengau ....................................

Denyut jantung ....................................

Refleks

- Muntah ....................................

- Batuk ....................................

- Okulokardiak ....................................

- Sinus karotikus ....................................

Sensorik

- 1/3 belakang lidah ....................................

N. Accessorius

Mengangkat bahu ....................................

Memutar kepala ....................................

N. Hypoglossus

Mengulur lidah ....................................

Fasikulasi ....................................

Atrofi papil ....................................

Disartria ....................................

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MOTORIK

LENGAN Kanan Kiri

Gerakan .................................... ....................................

Kekuatan .................................... ....................................

Tonus .................................... ....................................

Refleks fisiologis .................................... ....................................

Refleks patologis

- Hoffman Trommer ....................................

- Leri ....................................

- Meyer ....................................

TUNGKAI Kanan Kiri

Gerakan .................................... ....................................

Kekuatan .................................... ....................................

Tonus .................................... ....................................

Klonus

- Paha .................................... ....................................

- Kaki .................................... ....................................

Refleks fisiologis

- KPR .................................... ....................................

- APR .................................... ....................................

Refleks patologis

- Babinsky .................................... ....................................

- Chaddock .................................... ....................................

- Oppenheim .................................... ....................................

- Gordon .................................... ....................................

- Schaeffer .................................... ....................................

- Rossolimo .................................... ....................................

- Mendel Bechterew .................................... ....................................

Refleks kulit perut

- Atas ....................................

- Tengah ....................................

- Bawah ....................................

Refleks cremaster ....................................

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SENSORIK

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GAMBAR

FUNGSI VEGETATIF

Miksi : ....................................

Defekasi : ....................................

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KOLUMNA VERTEBRALIS

Kyphosis : ....................................

Lordosis : ....................................

Gibbus : ....................................

Deformitas : ....................................

Tumor : ....................................

Meningocele : ....................................

Hematoma : ....................................

Nyeri ketok : ....................................

GEJALA RANGSANG MENINGEAL

Kanan Kiri

Kaku kuduk ....................................

Kernig .................................... ....................................

Lasseque .................................... ....................................

Brudzinsky

- Neck ....................................

- Cheek ....................................

- Symphisis ....................................

- Leg I .................................... ....................................

- Leg II .................................... ....................................

GAIT DAN KESEIMBANGAN

Gait Keseimbangan dan Koordinasi

Ataxia : .................................... Romberg : ....................................

Hemiplegic : .................................... Dysmetri : ....................................

Scissor : .................................... - jari-jari : ....................................

Propulsion : .................................... - jari hidung : ....................................

Histeric : .................................... - tumit-tumit : ....................................

Limping : .................................... Rebound phenomen : ....................................

Steppage : .................................... Dysdiadochokinesis : ....................................

Astasia-Abasia: .................................... Trunk Ataxia : ....................................

Limb Ataxia : ....................................

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GERAKAN ABNORMAL

Tremor : ........................................................................

Chorea : ........................................................................

Athetosis : ........................................................................

Ballismus : ........................................................................

Dystoni : ........................................................................

Myocloni : ........................................................................

FUNGSI LUHUR

Afasia motorik : ........................................................................

Afasia sensorik : ........................................................................

Apraksia : ........................................................................

Agrafia : ........................................................................

Alexia : ........................................................................

Afasia nominal : ........................................................................

LABORATORIUM

DARAH

Hb : ....................................

Eritrosit : ....................................

Leukosit : ....................................

Trombosit : ....................................

Diff count : ....................................

Hematokrit : ....................................

BSS : ....................................

BSN/BSPP : ....................................

Kolesterol HDL : ....................................

Kolesterol LDL : ....................................

Trigliseride : ....................................

Total Lipid : ....................................

Uric Acid : ....................................

Ureum : ....................................

Kretinin : ....................................

WR/KAHN/VRDL : ....................................

URINE

Warna : ....................................

Reaksi : ....................................

Protein : ....................................

Reduksi : ....................................

Urobilin : ....................................

Bilirubin : ....................................

Sedimen :

- Eritrosit : ....................................

- Leukosit : ....................................

- Thorak : ....................................

- Sel Epitel : ....................................

- Bakteri : ..................................

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FAECES

Konsistensi : ....................................

Lendir : ....................................

Darah : ....................................

Amuba Coli : ....................................

Histolitika : ....................................

Eritrosit : ....................................

Leukosit : ....................................

Telur cacing : ....................................

LIQUOR CEREBROSPINALIS

Warna : ....................................

Kejernihan : ....................................

Tekanan : ....................................

Sel : ....................................

Nonne : ....................................

Pandy : ....................................

Protein : ....................................

Glukosa : ....................................

Nacl : ....................................

Queckensted : ....................................

Celloidal : ....................................

Culture : ....................................

PEMERIKSAAN KHUSUS

Rontgen foto cranium : ..............................................................................................................

Rontgen foto thoraks : ..............................................................................................................

Rontgen foto vertebralis : ..............................................................................................................

Electroencephalografi : ..............................................................................................................

Electroneuromyografi : ..............................................................................................................

Electrocardiografi : ..............................................................................................................

Arteriografi : ..............................................................................................................

Pneumografi : ..............................................................................................................

CT-Scan : ..............................................................................................................

Lain-lain : ..............................................................................................................

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RINGKASAN

ANAMNESA

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PEMERIKSAAN

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DIAGNOSA

DIAGNOSA KLINIK : ..................................................................................................

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DIAGNOSA TOPIK : ..................................................................................................

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DIAGNOSA ETIOLOGI : ..................................................................................................

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PENGOBATAN : ..................................................................................................

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PROGNOSA : ..................................................................................................

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