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7/25/2019 IR Pengisian Status Poli.docx

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  ase1ue (-%-)

  brag%si2ap (-%-)

  FA34R4 (-%-)

  FAIR (-%-)

  Siati huth pain (-%-)

#ST4#ART5RITIS

S : n'eri lutut 2anan +, 2a2u 2a2i 2anan epan, masih sering uu2 lesehan

# : St lo2alis genu *

  I : e$ormitas (-), tana raang (-)

  P: n'eri te2an tenon patella *

  : n'eri te2anarah am 67 an am 8 genu *

  " : R#" $ull, 2repitasi +

A : #A genu *

P : FT : IR genu *, T4NS genu *, ergo'le

  5P : P3" lutut

Hemiparesis

S: lemah anggota gera2 sinistra

#: parese N !II + 9II sinistra I9+9 sinistra

42stremitas Sup In$ 

;era2 +%menurun +%menurun

<e2uatan =% 8-8-8 =%8-8-8

 Tonus N% mening2at N% mening2at

RF +7%+8 +7%+8

RP -%+ -%+

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A: 5emiparesis Sinistra

P: FT bobath eerise

#T latihan A*

ST latihan arti2ulasi + menelan

LBP/OA

S : paha 2anan irasa2an 2esemutan sea2 7 bulan tera2hir, terutama saat beriri

lama an beralan auh

  n'eri lutut 2anan an 2iri, irasa n'eri saat posisi bangun ari uu2, 2a2u pagi

hari (+) > 60 menit

  ? ong2o2 (+), ri&a'at mono2 (-), ri&a'at 2an2er (-)

# : " <@ seang, 33 B,= 2g T3 6CB m

  status lo2alis genu *%S : 2repitasi (+%+), lait' (-%-), R#" $ull, hangat (-%-), NT

(-%-)

  AS4D@4 (-), 3RA;;AR* (-), SIAR* (-), patri2 (-), 2ontrapatri (-), poplitea

angle = eraat%= eraat

A: 3P suspE oitis (*)

  #A genu bilateral

P : FT : "?* hip (*), T4NS genu (*)

  e : strengtening 1uarieps (*)

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S :2eua 2a2i masih irasa2an berat, n'eri punggung (+)

  2emeng paha 2iri an tulang 2ering 2ananE

  3A3 an 3A< bn, mobilisasi bisa, ibantu saat a2an bangun tiur

  pulang mono2 8 hari 'll

# : " <@ seang

"otori2 Superior In$erior

  ;era2 +%+ +%+

  <e2uatan =% = 8%8

  Tonus N%N N% N

  Trof eu%eu eu%eu

RF +7%+7 +7%+7

  RP -%- -%-

  l -%-

  egetati$ bn

A : paraparese in$, 3P

P : FT : IR + T4NS lumbal

  : ba2 strengtening eE

  : strengtening A;3

PENULISAN SAUS PASIEN E!BA!U """"""

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S:

#: - Ne2

  R#": Full

  ""T: =

- Trun2

  R#": Full, n'eri (+)

  ""T: =

• 42stremitas Superior

- Shouler

  R#": Full , n'eri (+)

  ""T: =

- 4lbo&:

R#": Full

  ""T: =

- ?rist

  R#": Full

  ""T: =

- Finger

  R#": Full

  ""T :=

• 42stremitas In$erior

- 5ip

  R#": Full

  ""T: =

- <nee

  R#": Full

  ""T : =

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- An2le

  R#": Full

  ""T: =

- Toes

  R#": $ull

  ""T: =

 Status Lokalis: shouler etra n'eri te2an (+) i regio aromion %sinE <esan

shouler simetrisE Tana raang (-)E *e$ormitas (-)E Spasme paraertebralE

es k#usus: shouler etra apple' atas an ba&ah bisa, apple' (ar$ test) (-),

rop arm test (-)E 5a&2ins test (+), spee (+), empt' an test (+), neer test (+),

'ergason test (+)E

GH