Mata Ujian : ILMU BEDAH

Hari / Tanggal Ujian : .................................................

Rumah Sakit Margono Soekarjo
Nama Mahasiswa

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N.I.M.

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N.I.R.M.

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IDENTITAS PASIEN
Nama

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Jenis Kelamin

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Umur

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Bangsa

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Pekerjaan

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Agama

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Alamat

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I. ANAMNESIS
Diambil dari : _________________________________
1. Keluhan Utama :

2. Keluhan Tambahan :

3. Riwayat Penyakit :

Tanggal : ..........................

Jam : ...................

4. Riwayat Keluarga :

5. Riwayat Masa Lampau

1). Penyakit Terdahulu :

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2). Trauma Terdahulu :

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3). Operasi :

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4). Sistem Saraf :

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5). Sistem Kardiovaskuler :

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6). Sistem Gastrointestinal :

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7). Sistem Urinarius :

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8). Sistem Genitalis :

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9). Sistem Muskuloskeletal :

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10). Sistem Respiratorius :

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II. STATUS PRAESENS

1. STATUS UMUM
Keadaan umum :
Kesadaran :
Suhu :
Kulit :

Muka :

.................................................. Keadaan Gizi :

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.................................................. Pernafasan :

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Tekanan Darah :

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Kelenjar limfe : ..................................................

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Kepala :

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Telinga :

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Mulut / gigi :

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Perut :

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Hati :

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Limpa :

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Dada :

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Jantung :

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Leher :

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Hidung :

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Mata :

Nadi :

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Paru :

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Ginjal :

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Kandung empedu :

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Kandung kencing :

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Kemaluan :

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Rectum / Anus :

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Punggung :

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Ekstremitas :

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Refleks :

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2. STATUS LOKALIS

III. PEMERIKSAAN KHUSUS LAIN

IV. LABORATORIUM

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Sensibilitas :

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V. RESUME

VI. DIAGNOSIS KERJA

VII. DIAGNOSIS BANDING

VIII. PEMERIKSAAN ANJURAN

IX. PENGOBATAN

X. PROGNOSIS