Status Neurologi
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RSMH PALEMBANG RM.Srf.1 SMF SARAF ANAMNESIS Ruang : ....................................... No. Rek Med : ....................................... Nama : ....................................... Umur L/P : ....................................... Tanggal : .............................................. ....... Dokter Muda : ......................................... Dari : pasien sendiri/ayah/ibu/orang lain Dokter : ......................................... ........................................ ............. Chief : .........................................
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Transcript of Status Neurologi
RSMH PALEMBANGRM.Srf.1SMF SARAFANAMNESISRuang : ....................................... No. Rek Med : .......................................
Nama : ....................................... Umur L/P : .......................................
Tanggal : ..................................................... Dokter Muda : .........................................Dari : pasien sendiri/ayah/ibu/orang lain Dokter : ......................................... ..................................................... Chief : .........................................
RSMH PALEMBANGRM.Srf.2SMF SARAFPEMERIKSAANRuang : .................................... No. Rek Med : ....................................
Nama : .................................... Umur L/P : ....................................
Cor/pulmo:Abdomen:Gangguan psikis:Kesadaran:Tekanan Darah:Nadi:Suhu:Respirasi:Temperatur:PEMERIKSAAN FISIK UMUM (Tgl.......................)
Kepala/Leher :Saraf-saraf Otak :PEMERIKSAAN NEUROLOGIS (Tgl.......................)
RSMH PALEMBANGRM.Srf.3SMF SARAFPEMERIKSAANRuang : .................................... No. Rek Med : ....................................
Nama : .................................... Umur L/P : ....................................
MotorikLENGANDextraSinistraGerakan........................................................................................KekuatanFleksorEkstensorTangan........................................................................................................................................................................................................................................................................Tonus..........................................................................................Refleks FisiologisRefleks TendoBicepsTriceps................................................................................................................................................................................Refleks PeriostRadiusUlna................................................................................................................................................................................Refleks PatologisHoffman Tromner........................................................................................TUNGKAIDextraSinistraGerakan........................................................................................KekuatanFleksorEkstensorKaki........................................................................................................................................................................................................................................................................Tonus / Klonus..........................................................................................
RSMH PALEMBANGRM.Srf.4SMF SARAFPEMERIKSAANRuang : .................................... No. Rek Med : ....................................
Nama : .................................... Umur L/P : ....................................
Refleks FisiologisRefleks TendoKPRAPR................................................................................................................................................................................Refleks PatologisBabinskyChaddockOppenheimGordonSchafferRossolimoMendel Bechterew........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................REFLEKS KULIT PERUTAtas........................................................................................Tengah........................................................................................Bawah........................................................................................Sensorik:Tes Neurologis Lain (GRM, gait, gerakan abnormal, fungsi luhur, fungsi vegetatif):
RSMH PALEMBANGRM.Srf.5SMF SARAFPEMERIKSAANRuang : .................................... No. Rek Med : ....................................
Nama : .................................... Umur L/P : ....................................
LABORATORIUM (darah/urine/LCS):RADIOLOGI:HASIL:
RSMH PALEMBANGRM.Srf.6SMF SARAFPEMERIKSAANRuang : .................................... No. Rek Med : ....................................
Nama : .................................... Umur L/P : ....................................
DIAGNOSE NEUROLOGISDiagnosis Klinik: Diagnosis Topik: Diagnosis Etiologi: TERAPI (Tgl...............................)Residen: Co-Assisten: NIM:
SSS (Siriraj Stroke Score) Pasien Stroke
Nama Pasien: Umur : thn. Sex : MRS tanggal: Insult tanggal : Waktu serangan: Jam. Pemeriksaan klinis tanggal : Tekanan darah: / mmHgDiagnosa Klinis: Kesadaran: GCS15-14 (nilai 0) 13 - 8 (nilai 1) 7 3 (nilai 2) Muntah: Ada (nilai 1) Tidak ada (nilai 0) Cephalgia: Ada (nilai 1) Tidak ada (nilai 0) Diastolik: mmHgAtherom/gangguan PD : Ada (nilai 1) (DM, Angina Pain, Klaudikasio) Tidak ada (niali 0)
Rumus: (2,5(K) + 2(M) + 2(C) + 0,1(D) 3(A) 12)Hasil: Score SS:
Kesimpulan: Stroke hemoragik (>1) Stroke non hemoragik (
