STATUS NEUROLOGI (KSM NEUROLOGI RSUD ABEPURA)

IDENTITAS
Nama : .........................................................................
Jenis Kelamin : L/P
Umur : ....... Tahun
Alamat : ..........................................................................
Agama : Islam/KP/KK/Hindu/Budha
Pekerjaan : ..........................................
Status : Lajang/Menikah/Cerai/Duda/Janda
No RM : __ __ __
MRS Tanggal : ___/___/2018

ANAMNESA
Keluhan Utama : ..................................................................................................................
Riwayat Penyakit Sekarang : .......................................................................................................
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Riwayat Penyakit Dahulu : ....................................................................................................
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Riwayat Penyakit Keluarga : ....................................................................................................
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Sosial/Ekonomi/Kebiasaan : ....................................................................................................
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PEMERIKSAAN FISIK
Status generalis → KU : ...........................................................
Kes : ...........................................................
Pupil : .........................................................
TD : __/__ mmHg (MABP = ___) N : ___x/menit
(kuat angkat/tidak kuat angkat
RR : ___ x/menit reguler/ireguler)
SpO2 : ___% Sb : ___ OC

Mata/Wajah/Kulit : ......................................................................................................................
Telinga/Hidung/Tenggorokan : ...................................................................................................
Leher/Thorax : .............................................................................................................................
Jantung Paru :...............................................................................................................................
Abdomen : ...................................................................................................................................
Ekstremitas : ................................................................................................................................
Genetalia : ...................................................................................................................................

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Status Neurologis → GCS : E__M__V__ ( )
TRM → KK : ............... Laseque : ........./......... Kerniq : ..................
Nervus cranial :
I ...............................................
II ....................................................
III ...............................................
IV ...............................................
V ...............................................
VI ................................................
Motorik → Kekuatan Otot :
VII ..............................................
VIII ................................................
IX .................................................
X ....................................................
XI .................................................
XII ................................................
Tonus Otot :

RF : Bisep ......./....... Trisep ......./........ Patella ......./....... Achilles ....../......

RP : Hoffman-Tromner ......./........ Babinsky ......../........ Oppenheim ....../.....
Gonda ......./....... Schaeffer ......./........ Gordon ......../........ Chaddok ...../.....

PEMERIKSAAN PENUNJANG
Laboratorium :

Radiologi :
Siriraj Score:
Algoritma Gajah Mada :

DIAGNOSA
Klinis : ......................................................................................................
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Topis : ......................................................................................................
Etiologis : ......................................................................................................
Patologi : ......................................................................................................
Diagnosa lain : ......................................................................................................
Diagnosa Banding : ................................................................................................

TATALAKSANA

PROGNOSA
Ad Vitam :
Ad functionam :
Ad Sanactionam :

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