UNIVERSITAS YARSI

FAKULTAS KEDOKTERAN
MATA UJIAN : ILMU PENYAKIT DALAM
Hari/Tanggal Ujian :.
Rumah Sakit : .
Nama Mahasiswa : ____________________________________ Tandatangan :____________________
NIM : _______________________________________________________________________________
IDENTIFIKASI PASIEN
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Nama lengkap : _______________________________________________________________________
Tempat/Tanggal lahir/ Umur : ____________________________________________________________
Status perkawinan : ____________________________________________________________________
Pekerjaan : ___________________________________________________________________________
Alamat : _____________________________________________________________________________
A.ANAMESIS
Diambil dari _____________________ Tanggal : _____________________ Jam : __________________
Keluhan Utama :
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Riwayat Penyakit Sekarang :
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Penyakit Dahulu (Tahun)

(
) Cacar
(
) Cacar air
(
) Difteri
(
) Batuk Rejan
(
) Campak
(
) Influenza
(
) Tonsilitis
(
) Kholera
(
) Demam Rematik Akut
(
) Pneumonia
(
) Pleuritis
(
) Tuberkolusis
Lain-lain :
Operasi :

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Malaria
Disentri
Hepatitis
Tifus Abnominalis
Skirofula
Sifilis
Gonore
Hipertensi
Ulkus Ventrikuli
Ulkus Duodeni
Gastritis
Batu Empedu

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Batu ginjal/ UTI

Hernia
Penyakit Prostat
Wasir
Diabetes
Alergi
Tumor
Penyakit Pem. Darah
Perdarahan Otak
Psikosis
Neurosis

Kecelakaan :

Riwayat Keluarga
Hubungan
Kakek
Nenek
Ayah
Ibu
Saudara
Anak-anak

Umur (tahun)

Adakah kerabat yang menderita

Penyakit
Ya
Asma
Alergi
Tuberkolusa
Artritis
Rematisme
Hipertensi
Jantung
Ginjal
Lambung

Keadaan Kesehatan

Tidak

ANAMESIS SISTEM
Catatan keluhan tambahan positif disamping judul judul yang bersangkutan
Kulit

Penyebab Kematian

Hubungan

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Bisul
Kuku
Lain-lain :

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(

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)

Rambut
Kuning/Ikterus

Kepala
(
) Trauma
(
) Sinkop
(
) Lain-lain :

(
(

)
)

Sakit kepala
Nyeri pada sinus

Mata
(
)
(
)
(
)

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(

)
)

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Nyeri
Sekret
Lain-lain :

Telinga
(
) Nyeri
(
) Sekret
(
) Lain-lain :
Hidung
(
) Trauma
(
) Nyeri
(
) Gang. penciuman
Mulut
(
)
(
)
(
)

Bibir
Gusi
Lain-lain :

(
(

)
)

Keringat Malam
Sianosis

Kuning/Ikterus
Gang. peglihatan

(
(

)
)

Radang keringat malam

Ketajaman Penglihatan

)
)

Gang. pendengaran
Tinitus

Kehilangan
pendengaran

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(

)
)
)

Sekret
Epistaksis
Lain-lain :

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(

)
)

Pilek
Gejala penyumbatan

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(

)
)

Gangguan pengecap
Lidah

(
(

)
)

Lidah
Stomatitis

)
)

Ortopneu
Batuk

Tenggorokan
(
) Nyeri Tenggorok
(
) Lain-lain :

Perubahan Suara

Leher
(
)
(
)

Nyeri Leher

Benjolan
Lain-lain :

Dada (Jantung/Paru)
(
) Nyeri dada
(
) Sesak napas
(
) Lain-lain :

Abdomen (Lambung/Usus)

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(

)
)

Berdebar
Batuk darah

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(

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Rasa kembung
Mual
Muntah
Muntah darah
Lain-lain :

Saluran Kemih
(
) Stragnuri
(
) Poliuria
(
) Disuria
(
) Hematuria
(
) Kencing menetes
(
) Lain-lain :

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Sukar menelan
Nyeri perut,kolik
Perut membesar
Wasir

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Polaklsuria
Kencing batu
Ngompol(tidak disadari)
Retensi urin
Penyakit Prostat

Katamenis
(
) Leukore
(
) Lain-lain :
Haid (
(

)
Haid terakhir
Teratur/ tidak
Pasea mesopgus
Lain-lain :

Saraf dan otot

(
) Anestesi
(
) Parestesi
(
) Otot lemah
(
) Kejang
(
) Lain-lain :

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(

Mencret
Tinja berdarah
Tinja warna dempul
Benjolan

)
)
)
)
)

Kencing nanah
Kolik
Oliguri
Anuria

Perdarahan

(
(
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)

Jumlah dan Lamanya

Ganguan haid
Nyeri haid

(
(

)
)

Menarche
Gejala

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)

Ataksia
Sukar menggigit
Amnesis
Afasia

(
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)

Hipo/Hiper estesi
Pingsan
Tic
Vertigo

Ekstremitas
(
) Bengkak
(
) Nyeri Sendi
(
) Lain-lain :
BERAT BADAN
Berat badan rata-rata (kg) :
Berat/Tinggi (kg/cm) (kapan) :
Berat badan sekarang (kg) :
(Bila pasien tidak tahu dengan pasti)
(
) Tetap
(
) Naik
(
) Turun

(
(

)
)

Deformitas
Sianosis

RIWAYAT HIDUP
Tempat Lahir
Ditolong

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Dirumah
Dokter

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)

Rumah Bersalin
Bidan

(
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)

Dukun

Riwayat Makanan :
Frekuensi / Hari :
Jumlah / Hari :
Variasi / Hari :
Nafsu makan :
Pendidikan
(
) SD
(
) SMP
Kesulitan
Keuangan
Pekerjaan
Keluarga
Lain-lain

(
(

)
)

SMA
Perguruan tinggi

(
(

;
:
:
:

PEMERIKSAAN JASMANI
Pemeriksaan Umum
Tinggi badan :
Berat badan
:
Tekanan darah :
Nadi
:
Suhu
:
Pernafasan
:
Keadaan Gizi :
Kesadaran
:
Sianosis
:

Tipe :

)
)

Akademi
Kursus

(
(

)
)

Kejuruan
Tidak Sekolah

Edema umum
Habitus
Cara berjalan
Mobilitas
Taksiran umur

:
:
:
:
:

ASPEK KEJIWAAN
Tingkah laku :
Alam perasaan :
Proses piker
:

wajar / gelisah / tenang / hiperaktif / hipoaktif

biasa / sedih / gembira / cemas / takut / marah
wajar / cepat / gangguan waham / fobia / obsesi

KULIT
Warna
Jaringan Parut
Pertumbuhan rambut
Suhu raba
Keringat
Lapisan lemak
Lain-lain

:
:
:
:
:
:
:

KELENJAR GETAH BENING

Submadibula
:
Supraklavikula
:
Lipat paha
:
KEPALA
Ekspresi wajah
:
Pembuluh darah temporal

Umum / Setempat

Eflorensi
:
Pigmentasi
:
Pembuluh darah ;
Tugor
:
Ikterus
:
Edema
:

Leher
Ketiak

:
:

Simetri muka
Rambut

:
:

MATA
Eksoptalmus
Kelopak
Konjungtiva
Lapangan pandang
Deviatio konjungae
TELINGA
Tuli
Lubang
Cairan

:
:
:
:
:

Enopthalmus
Lensa
Visus
Tekanan bola mata
Nystagmus

:
:
:
:
:

:
:
:

Gendang telinga
Serumen
Penyumbatan

:
:
:

Pendarahan
MULUT
Bibir
Tonsil
Faring
Trismus

:
:
:

Langit-langit
Gigi geligi
Lidah
Selaput lendir

:
:
:
:

LEHER
Tekanan JVP
Kelenjar tiroid
Kelenjar limfa

:
:
:

Bentuk
Pembuluh darah
Buah dada

:
:
:

DADA

PARU PARU
Depan
Inspeksi
Palpasi
Perkusi
Auskultasi

Belakang

Kanan
Kiri
Kanan
Kiri
Kanan
Kiri
Kanan
Kiri

JANTUNG
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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PEMBULUH DARAH
Arteri Temporalis
:
Arteri Karotis
:
Arteri Brakhialis
:
Arteri Radialis
:
Arteri Femoralis
:
Arteri Poplitea
:
Arteri Tibialis Posterior :
PERUT
Inspeksi
Palpasi dinding perut
Hati
Limfa
Ginjal
Lainnya
Perkusi
Auskultasi
Refleks dinding perut

:
:
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ALAT KELAMIN (ATAS INDIKASI)

Laki-laki
Penis
Skrotum
Testis
ANGGOTA GERAK
Lengan
Otot
Tonus
Masa
Sendi
Gerak

Wanita
Genitalia eksterna
Flour albus/darah

Kanan

Kiri

Kekuatan
Lain-lain

Tungkai dan Kaki

Luka
Varises
Otot
Tonus
Masa
Sendi
Gerakan
Kekuatan
Edema
Lain-lain

Kanan

Kiri

COLOK DUBUR (ATAS INDIKASI)

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LABORATORIUM
Darah
:
Hb:
Hitung jenis:
Lain-lain :
Urin lengkap

Ht:

Leukosit:

Trombosit:

L.E.D:

Tinja Lengkap :
RINGKASAN

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Diagnosis kerja dan dasar diagnosis

Diagnosis kerja :
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Dasar Diagnosis :
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Diagnosis banding :
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Dasar diagnosis banding :

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Pemeriksaan yang dianjurkan :
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Rencana pengelolaan :
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Pencegahan :
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Prognosis
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