UH

A MM A D

RS

AH
N

E M B A

IDENTIFIKASI
Nama Lengkap
Jenis Kelamin
Tgl Lahir/Umur
Alamat
Pekerjaan
Agama

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No. Reg. RS
Tgl Pemeriksaan
Ruang
Dokter Pemeriksa
Co.asisten
MRS Tanggal

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ANAMNESA
Keluhan utama oleh penderita/keluarga/orang yang berhubungan dengan penderita

Riwayat Perjalanan Penyakit

FAKULTAS KEDOKTERAN UMP/

RS MUHAMMADIYAH PALEMBANG
REKAM MEDIK KEPANITERAAN KLINIK

Riwayat Penyakit yang Pernah Diderita

Cacar Air
Tuberculosis
Batu Empedu
Cacar
Malaria
Batu Ginjal
Difteria
Disentri
Burut
Batuk

Riwayat Keluarga
Hubungan Umur
Ayah

Kelamin

Hepatitis
Kencing Manis
Campak
Thypus Abdominalis
Tumor
Influenza
Scrofuloderma
CVA
Cholera
Syphilis

Kesehatan

Meninggal

Ibu

Suami/Istri

Saudara/i

Anak-anak

Psikosis
Demam Rematik
Hipertensi
Neurosis
Pneumonia
Ulkus Peptikum
Pleuritis
Gastritis
Lain-lain

Riwayat Penyakit Dalam Keluarga

Ya/
Hub. dg
Penyakit
Tidak Keluarga
Alergi
Asthma
Arthritis
Diabetes
Jantung
Ginjal
Hipertensi
Kanker
Lambung
Rheumatic
Syphilis
Epilepsy
Sakit Jiwa
Bunuh diri
Tuberculosis
Lain-lain

Nama/Umur/Jenis Kelamin : ........................................

Ruangan : .....................

RIWAYAT HIDUP

TEMPAT LAHIR
Rumah : .............................
PARTUS
Spontan : ........................

Rumah Bersalin : .............................

Tindakan Khusus : ........................

RS : .............................

Tdk Ketahui : ........................

MASA KANAK-KANAK (Peristiwa Penting)

....................................................................................................................................................................
SIKAP TERHADAP
Ayah : .............................
PENDIDIKAN
SD : .............................

Ibu : .............................

Saudara : .............................

SMP : .............................

SMA : .............................

PEKERJAAN :
Bidang Kantor : .............................

Industri : .............................

Lain-lain : .............................

PERKAWINAN
Lama Perkawinan sekarang : ............................. Jumlah Perkawinan : .............................
Jumlah Anak : .............................
Pengaturan Perkawinan : .............................
PERUMAHAN
Rumah Sendiri : .............................
Kontrak/Sewa : .............................

Beli
: .............................
Kantor : .............................

KEBIASAAN
Merokok : .............................
Jamu : ............................. Olahraga : .............................
Kopi : ............................
Minuman keras : .............................
Rekreasi : .............................
Teh : .............................
Obat-obatan : .............................
Lain-lain : .............................
TIDUR
Berapa jam

: .............................

Teratur/tidak : .............................

GIZI
Berapa kali makan : .............................
Banyaknya : .............................
Teratur/tidak : .............................
Variasi (perinci) : .............................
KESULITAN
Keuangan : .........................................
Keluarga : .........................................

Nafsu Makan : .............................

Pencernaan
: .............................
Komposisi
: .............................

Pekerjaan : ...................................
Lain-lain : ...................................
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Catatan keluhan tambahan positif

disamping jenis yang bersangkutan

Keluhan Organ

Kulit
Bisul
Kuku

Rambut
Lain-lain

Kepala
Trauma
Sekret

Sakit kepala
Nyeri pada sinus

Mata
Nyeri
Sekret
Kacamata

Radang
Gangguan penglihatan
Penglihatan kurang jelas

Telinga
Nyeri
Sekret
Nyeri Tekan

Tinitus
Gangguan pendengeran
Kehilangan pendengaran

Hidung
Trauma
Nyeri
Sekret
Epistaksis

Pilek
Gejala penyumbatan
Post Nasal Drip
Gangguan Alat pembau

Mulut
Mulut
Gusi
Selaput Lendir
Gigi-Geligi

Lidah
Gangguan Mengecap
Gangguan Mengunyah
Sekresi Lidah

Tenggorokan
Tonsillitis
Laryngitis

Nyeri Tenggorokan
Abses Peritonsilar
Perubahan Suara

Leher
Thyroid

Adenitis

Jantung/Paru-paru
Nyeri dada
Berdebar-debar
Sesak Nafas
Edema
Orthopnue

Batuk
Dahak
Sianosis
Serangan Asma
Keringat malam hari

Lambung/Usus
Rasa Kembung
Mual
Muntah
Nyeri (sifat)
Sukar menelan
Muntah darah
Ikterus

Wasir
Mencret
Tinja berwarna
- Dempul
- Teh
- Nanah
Lain-lain

Alat Kencing/Kelamin
Disuria
Anuria Retensi
Oligouria
Poliuria
Hematuria
Kencing nanah

Ngompol
Kencing manis
Inkontinensia
Penyakit Prostat
Kolik Ginjal
Kolik Ureter

Katanemia
Menarche
Haid
- Haid terakhir :
- Teratur/tdk
- Lama :
- Jumlah :
- Nyeri/tdk :
Leukorrhea
Gejala Klimaterium
Sakit kepala
Lain-lain

Syaraf dan Otot

Perangai :
Ingatan :
Disposisi
Kerisauan
Gelisah :
Pusing (vertigo) :
Serangan Pingsan :
Gangguan panca indera :
Neurologis :
Kejutan :
Kejang :
Parestesi:
Ataxia :
Nyeri otot dan sendi yang menyayat:
Atropi otot :
Paresis/Paralysis :
Lain-lain

Berat badan
Berat badan rata-rata :
Berat badan tertinggi (kapan) :
Tetap/Turun/Naik
Berat badan :
Dalam waktu berapa bulan :
Berat sekarang :

Tinggi badan :

PEMERIKSAAN FISIK
KEADAAN UMUM

Keadaan Sakit
: Tidak tampak sakit/sedang sakit ringan/sedang/berat
Kesadaran
:
Anemia
:
Sianosis
:
Dyspnoe/Orthopnoe
:
Oedema Umum
:
Dehidrasi
:
Keadaan Gizi
:
Bentuk badan/habitus
:
Kebersihan
:
Cara Berjalan
:
Cara berbaring/morbiditas
:
Umur menurut dugaan pemeriksa :
Nadi/pulse rate
:
- Frekuensi
:
- Tegangan
:
- Irama
:
- Gelombang :
- Isi
:
- Kualitas
:
Pernafasan
- Frekuensi
:
- Irama
:
- Tipe
:
Berat badan
:
kg
Tinggi badan
:
cm
0
Tempratur
:
C
Tekanan darah
:
mmHg

Kulit
Warna
:
Efloresensi
:
Pigmentasi
:
Jaringan Parut
:
Turgor
:
Keringat
- Umum
:
- Setempat
:
Pertumbuhan rambut
Lapisan Lemak
Ikterus
Lembab/kering

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Kelenjar Getah Bening

Submandibula
Leher
Subclavicula
Axilla
Anal
Inguinal

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PEMERIKSAAN ORGAN
1. Kepala
Bentuk
:
Ekspresi
:
Simetri muka :
Rambut
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2.

3.

4.

5.

6.

7.

Deformasi
Perdarahan Temporal
Nyeri tekan
Bising

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Mata
Exopthalmus
Enopthalmus
Kelopak
Conjunctiva
Palbebra
Bulbi

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Sclera
Cornea
Pupil
Visus
Gerakan
Lap. Pandang

Telinga
Lubang
Selaput
Pendengaran

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Tophi
:
Nyeri tekan :
Promastoideus :

Hidung
Bagian luar
Septum
Selaput Lendir

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Ingus
:
Penyumbatan :
Perdarahan
:

Mulut
Bibir
Gigi-Geligi
Gusi
Lidah

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Selaput lendir
Pharynx
Tonsil
Bau pernafasan

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Tekanan vena
Kaku kuduk
Tumor

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Leher
Kel. Getah bening
Kel. Gondok
Trachea
Dada
Bentuk
Pembuluh darah
Buah dada
Nyeri tekan
Nyeri ketok
Krepitasi

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8.

Paru-paru
DEPAN
Kanan
Inspeksi

Palpasi

Perkusi

Auskultasi :

Kiri

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BELAKANG
Kanan
Inspeksi

Palpasi

Perkusi

Auskultasi :

Kiri

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9.

Jantung
Inspeksi :
Palpasi

Perkusi

Auskultas :

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10. Pembuluh Darah

a. Temporalis
:
a. Carotis
:
a. Brachialis
:
a. Radialis
:
11. Perut
Inspeksi
Palpasi
Perkusi
Auskultasi
Hati
Limfa
Ginjal
Lain-lain
Refleks

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a. Femoralis
a. Poplitea
a. Tibialis posterior
a. Dorsalis pedis

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12. Ekstremitas
Kiri

Kanan

Lengan
- Tonus
- Gerakan
- Kekuatan
- Otot
- Sendi
- Lain-lain

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Tangan
- Warna telapak
- Kuku
- Tremor
- Ujung Jari
- Kelainan jari
- Lain-lain

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Tungkai dan kaki

- Tonus
- Gerakan
- Kekuatan
- Otot
- Sendi
- Varises
- Parut
- Luka
- Edema

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Refleks
- Bicceps
- Triceps
- Patella
- Achilles
- Cremaster
- Babynski
- Kernig

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13. Genitalia Eksterna

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NAMA : .....................................................

RUANGAN : ......................................

LABORATORIUM DAN PEMERIKSAAN TAMBAHAN

TANGGAL
PEMERIKSAAN PENUNJANG
KETERANGAN

TANGGAL

PEMERIKSAAN PENUNJANG

KETERANGAN

TANGGAL

PEMERIKSAAN PENUNJANG

KETERANGAN

TANGGAL

PEMERIKSAAN PENUNJANG

KETERANGAN

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RINGKASAN
(Cerita singkat penemuan positif dan anamnesis, pemeriksaan fisik dan laboratorium yang menuju ke
diagnosa)
Nama/Umur/Jenis Kelamin :
Ruangan
:
Anamnesis

Pemeriksaan Fisik

Laboratorium

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Diagnosis Sementara
...........................................................................................................................
...........................................................................................................................
Diagnosis Banding
1. ..................................................................................................................
2. ..................................................................................................................
3. ..................................................................................................................
4. .................................................................................................................
5. ..................................................................................................................

Pengobatan
1. .................................................................................................................
2. .................................................................................................................
3. .................................................................................................................
4. .................................................................................................................
5. .................................................................................................................
6. ................................................................................................................
7. ................................................................................................................
8. ................................................................................................................
9. .................................................................................................................
10. .................................................................................................................
Prognosa
Quo ad vitam : .................................................................................................
Quo ad functionan : ........................................................................................
Rencana Pemeriksaan khusus
1. .......................................................................................................................
2. .......................................................................................................................
3. .......................................................................................................................
4. .......................................................................................................................
5. .......................................................................................................................
6. .......................................................................................................................
7. .......................................................................................................................
8. .......................................................................................................................

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TGL

S
O
A
P

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LEMBAR FOLLOW UP
KOAS PENYAKIT DALAM
O
A

Subjektif (sign + simptom)

Objektif (PF + pemeriksaan penunjang)
Assesment (kesimpulan, daftar masalah dan analisis)
Planning (non Farmokologi dan Farmakologi)
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