FAKULTAS KEDOKTERAN UNILA

PUSKESMAS RAWAT INAP KEDATON

BANDAR LAMPUNG
STATUS MAHASISWA FINAL SEMESTER

Nama Mahasiswa
NPM

TANGGAL

: _________________

RUANG

: _________________

: ____________________
: ____________________

Tanda Tangan : ___________

IDENTITAS PASIEN
Nama
: ___________________

Jenis Kelamin : ___________________

Umur

: ___________________

Bangsa

: ___________________

Pekerjaan

: ___________________

Agama

: ___________________

Alamat

: ___________________

I. ANAMNESIS
Diambil dari : ___________________

Tanggal : _______________

Jam :_________

1. Keluhan Utama
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2. Keluhan Tambahan
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3. Riwayat Penyakit
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4. Riwayat Keluarga
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5. Riwayat masa lampau
a. Penyakit terdahulu
b. Trauma terdahulu
c. Operasi
d. Sistem saraf
e. Sistem kardiovaskuler
f. Sistem gastrointestinal
g. Sistem urinarius
h. Sistem genitalis
i. Sistem muskuloskeletal

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II. STATUS PRESENT

A. STATUS UMUM
Keadaan Umum
Kesadaran
Keadaan gizi
Kulit

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B. PEMERIKSAAN FISIK
TANDA VITAL
Tekanan Darah
Pernafasan

: _________ mmHg
: _________ x/menit

Nadi
Suhu

: _________ x/menit
: _________ oC

KEPALA DAN MUKA

o Bentuk dan Ukuran
: _________________________________________________________
o Mata : _________________________________________________________
Konjungtiva
: _____________________
Refleks Cahaya :
Sklera
: _____________________ Pupil
: ___________________
o
o
o
o
o

Telinga
Hidung
Tenggorokan
Mulut :
Gigi :

: _________________________________________________________
: _________________________________________________________
: _________________________________________________________

LEHER
o Kelenjar Getah Bening : _________________________________________________________
o Kelenjar Gondok
: _________________________________________________________
o JVP :
DADA (THORAX)
o Inspeksi
o Palpasi :
o Perkusi
o Auskultasi
PERUT (ABDOMEN)
o Inspeksi
o Palpasi
o Perkusi
o Auskultasi

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REGIO LUMBAL (FLANK AREA)

o Inspeksi
: _________________________________________________________
o Palpasi
: _________________________________________________________
o Perkusi
: _________________________________________________________
o Auskultasi
: _________________________________________________________
EKSTREMITAS
o Superior
o Inferior

: _________________________________________________________
: _________________________________________________________

GENITALIA
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PERIANAL
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2

 NEURO MUSKULAR
o Sensibilitas
: ____________________________________________________________
o Refleks fisiologis : ____________________________________________________________
o Refleks patologis : ____________________________________________________________
TULANG BELAKANG
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C. STATUS LOKALIS
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III. LABORATORIUM RUTIN
A. Darah Rutin
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B. Urine Rutin
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C. Feses Rutin
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IV. DIAGNOSA BANDING
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V.

DIAGNOSA KERJA
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VI. PEMERIKSAAN PENUNJANG

A. RADIOLOGI
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B. LABORATORIUM KHUSUS
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VII. RESUME
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VIII. PEMERIKSAAN ANJURAN
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IX.

PENATALAKSANAAN DAN PENGOBATAN

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X.

PROGNOSIS
Quo ad vitam
:
Quo ad fungtionam :
Quo ad sanatinam :