PEMERIKSAAN FISIK DASAR KELAINAN ORTHOPAEDIDr. Hari Tjahyono, SpOT

DATA History Physical examination Photo Laboratorium

HISTORYKeluhan utama- Pain :- Nyeri- Anestesi- Parestesi- Penurunan fungsi- Physical Appearance- Deformity- Atrophy- Scoliosis- Relevant past history : penyakit sebelumnya- Penyakit penyerta : Jantung, ren, diabetus melitus, respiratory, psychic- Family history

Physical examination Body build : Wajah, gait (walking),

duduk, tidur Looking (inspection) Feeling (palpation) Moving (Assessment of joint motion) Listening (auscultation) Special physical test Neurological examination

LOOK (INSPECTION) Warna kulit : merah, cyanosis,

pigmentation, pucat, luka Swelling Limb shortening / atrophy Gait

FEEL (PALPATION) Hangat Dingin Size (ukuran) Dislocation Crepitus

MOVE (ASSESSMENT OF JOINT MOTION) Passive movement Joint instability Range of motion

LISTENING (AUSCULTATION) Crepitus Snapping tendon Murmur arteriorvenous fistula

PHYSICAL TEST Flexion deformity : Thomas test Trendelenburg test Instability:- Ortholani

- Laseque Test- Mc Murray Test Neurological examination :

- Muscle : Weakness Spasticity- Sensation- In coordination- Reflex tendon

RADIOGRAPHIC EXAMINATION Identitas pasien Tulang :

AP Lateral melampaui kedua sendi Densitas naik : sclerosis Rarefaction General density, local density Hubungan tulang : dislocation, subluxasi Break in bone : fracture line (transfer, Oblique, segmental, comminutive, rotasi, cumcontractionum, cumdistractionum, angulasi) General / local countour : Deformity, Irregularity

RADIOGRAPHIC EXAMINATION Sendi

Articular cartilage : Space sendi Soft tissue Comparation of a limb Special photo : contras / medium

Arthrogram: dalam sendiMyelogram: sub arachnoidSinosgram: dalam sinus CT Scan MRI Bone Survey

LABORATORIUM EXAMINATION Darah lengkap Leukocyte, LED, Thrombocyte, HB Serum : Mantoux (TBC)

Rose test (Rheumathoid desease) Urine : - Albumin, gula, cell, kristal

- Cultur Cerebro spinal fluid : Protein, cell, Cultur Abnormal fluids : Effusion, Exudates

Gross, smear, cultur, resistance antibiotic

BODY TISSUE Gross Biopsi

Semua data dikorelasikan untuk diagnose dan diferensial diagnose