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FAKULTAS KEDOKTERAN ..................

SMF BEDAH RSUD Dr. Hi. ABDUL MOELOEK


BANDAR LAMPUNG
STATUS MAHASISWA ILMU BEDAH
Tanggal
: _________________
Rumah Sakit
: _________________
Nama Mahasiswa : ____________________
NPM
: ____________________
__
IDENTITAS PASIEN
Nama
: ___________________
___
Umur
: ___________________
_____
Pekerjaan
: ___________________
Alamat
: ___________________
I. ANAMNESIS
Diambil dari
: ___________________
Jam :_________

Tanda Tangan : _________

Jenis Kelamin : ________________


Bangsa

: ______________

Agama : ___________________
No MR. : ___________________
Tanggal : _______________

1. Keluhan Utama
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
___
2. Keluhan Tambahan
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
___
3. Riwayat Penyakit
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
___________
4. Riwayat Keluarga
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____
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
: ______________________________________________
____________

II. STATUS PRESENT


A. STATUS UMUM
Keadaan Umum
:
Kesadaran
:
Keadaan gizi
:
Kulit :
B. PEMERIKSAAN FISIK
?
TANDA VITAL
Tekanan Darah : _________ mmHg
Pernafasan
: _________ 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
:

?
o
o
o

LEHER
Kelenjar Getah Bening
Kelenjar Gondok :
JVP
:

?
o
o
o
o

DADA (THORAX)
Inspeksi
Palpasi :
Perkusi
Auskultasi

?
o
o
o
o

PERUT (ABDOMEN)
Inspeksi
Palpasi
Perkusi
Auskultasi

REGIO LUMBAL (FLANK AREA)

:
:
:
:
:
:
:

o
o
o
o

Inspeksi
Palpasi
Perkusi
Auskultasi

:
:
:
:

?
o
o

EKSTREMITAS
Superior
Inferior

:
:

GENITALIA

PERIANAL

NEURO MUSKULAR

o
o
o

Sensibilitas
:
Refleks fisiologis
Refleks patologis

TULANG BELAKANG

:
:

C. STATUS LOKALIS
III. LABORATORIUM RUTIN
A. Darah Rutin
B. Urine Rutin
C. Feses Rutin
IV.

RESUME

V.

DIAGNOSA BANDING

VI.

DIAGNOSA KERJA

VII.

PENATALAKSANAAN DAN PENGOBATAN

VIII.

PEMERIKSAAN PENUNJANG

A.

RADIOLOGI

B.

LABORATORIUM KHUSUS

IX.

PEMERIKSAAN ANJURAN

X.

PROGNOSIS

XI.

TINJAUAN PUSTAKA (PADA CASE REPORT)