FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNGPURA / RSUD. DR.

SOEDARSO PONTIANAK
SMF ILMU PENYAKIT DALAM

DATA DASAR PASIEN

I.

IDENTITAS
1.
2.
3.
4.
5.
6.
7.

Nama lengkap
Jenis Kelamin
Umur
Suku / Bangsa
Agama
Pekerjaan
Alamat

8. Status Perkawinan
II.

: ............................................................................................................
: Laki-laki / Perempuan
: .........................Tahun, ...........................Bulan, ........................Hari
:................................................... / .......................................................
: Islam / Kristen / Katolik / Hindu / Budha / ....................
: ............................................................................................................
: ............................................................................................................
.............................................................................................................
: Kawin / Belum Kawin / Duda / Janda

ANAMNESIS
1. Keluhan Utama :...................................................................................................................................................
2. Riwayat Penyakit
Sekarang : ............................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
1

FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNGPURA / RSUD. DR. SOEDARSO PONTIANAK

SMF ILMU PENYAKIT DALAM
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
3. Riwayat Penyakit Dahulu :
..............................................................................................................................................................................
..............................................................................................................................................................................
.............................................................................................................................................................................
2

FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNGPURA / RSUD. DR. SOEDARSO PONTIANAK

SMF ILMU PENYAKIT DALAM
4. Riwayat Penyakit Keluarga :

...
III.

KELUHAN SISTEMIK
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.

IV.

Kulit
Kepala
Mata
Telinga
Hidung
Mulut
Tenggorok
Leher
Dada
Paru
Jantung
Abdomen
Anus/ Rektum
Alat Kelamin

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

PEMERIKSAAN FISIK

A. Kesan umum : .............................................................................................................................

B. Tanda Vital
a. Kesadaran
: ..........................
b. Tekanan darah
: ......................... mmHg
c.
d.
e.
C.

Nadi
Laju Nafas
Suhu

: ........................ x /menit, irama: ....................... , isi: ..........................

: ........................ x /menit, tipe ............................................
: ....................... c

Pemeriksaan Per Organ

a. Kulit
b. Kepala
c. Mata

: .................................................................................................................................................
: ............................................................................................................ .....................................
: ............................................................................................................ .....................................
......................................
d. Telinga
: ............................................................................................................ .....................................
e. Hidung
: ............................................................................................................ .....................................
f. Mulut
: ............................................................................................................ .....................................
g. Tenggorok : ............................................................................................................ .....................................
h. Leher
: ............................................................................................................ .....................................
i. Dada
: ..................................................................................................................................................
j.

Paru
Inspeksi : .................................................................................................................................................
Palpasi : .................................................................................................................................................
Perkusi : .................................................................................................................................................
Auskultasi : .............................................................................................................................................

k. Jantung
Inspeksi
Palpasi
Perkusi

: .....................................................................................................................................
: ....................................................................................................................................
: ....................................................................................................................................
3

FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNGPURA / RSUD. DR. SOEDARSO PONTIANAK

SMF ILMU PENYAKIT DALAM
....................................................................................................................................
.....
Auskultasi
: ....................................................................................................................................
l.

Abdomen
Inspeksi
Auskultasi
Palpasi

Perkusi
m. Anus / Rektum
n. Alat Kelamin
/ Perineum
o. Ekstremitas
p. Nervi craniales
q. Limfonodi
V.

VI.

VII.

VIII.

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

STATUS LOKALIS
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
RESUME
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
.............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
DIANOSA SEMENTARA/ TETAP
1. ................................................................................................................................................
2. ................................................................................................................................................
3.
DIAGNOSA BANDING
1. ...............................................................................................................................................
2. ...............................................................................................................................................
3. ...............................................................................................................................................

IX.

TERAPI / TATALAKSANA
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
.............................................................................................................................................................................
4

FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNGPURA / RSUD. DR. SOEDARSO PONTIANAK

SMF ILMU PENYAKIT DALAM
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
X.

PROGRAM / PEMERIKSAAN PENUNJANG

1. ...............................................................................................................................................
2. ...............................................................................................................................................
3. ...............................................................................................................................................

XI.

PROGNOSIS
1. ...............................................................................................................................................
2. ...............................................................................................................................................
3. ...............................................................................................................................................
Pontianak, ..........................................
Pemeriksa
( .........................................................)