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BAGIAN ILMU KESEHATAN ANAK

FAKULTAS KEDOKTERAN UNIVERSITAS TRISAKTI


RS PENDIDIKAN : RSUD BUDHI ASIH
JAKARTA
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STATUS PASIEN KEPANITERAAN
Nama Koasisten

Tanggal Pengelolaan

...............................................

Nama Dokter Pembimbing

Periode Bimbingan

...............................................

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IDENTITAS
Nama Pasien
: .....................................................................................................
Jenis Kelamin : .....................................................................................................
Agama
: .....................................................................................................
Alamat Rumah : .....................................................................................................
Tempat Tanggal Lahir / Umur : ................................................................................
Pendidikan
: .....................................................................................................
Ayah

Nama
Agama
Alamat
Pekerjaan
Penghasilan

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

Ibu

Nama
Agama
Alamat
Pekerjaan
Penghasilan

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

Wali

Nama
: .....................................................................................................
Agama
: .....................................................................................................
Alamat
: .....................................................................................................
Pekerjaan
: .....................................................................................................
Penghasilan : .....................................................................................................
Hubungan dengan orang tua
: Anak kandung / Angkat / Tiri Asuh
Suku bangsa/bangsa
:

RIWAYAT PENYAKIT :

KELUHAN UTAMA :
...............................................................................................................................
KELUHAN TAMBAHAN :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
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RIWAYAT PENYAKIT SEKARANG :
(Lengkap, rinci, jelas, dan terarah)
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RIWAYAT KEHAMILAN / KELAHIRAN


KEHAMILAN
KELAHIRAN

Morbiditas Kehamilan
Perawatan Antenatal
Tempat Kelahiran

Rumah Sakit / Rumah Bersalin / Rumah


Lain-lain ...............................................
Penolong Persalinan
Dokter / Bidan / Dukun
Lainnya ...................................................
Cara Persalinan
Spontan
Penyulit / Kelainan
Tindakan
Sectio Caesaria
Masa Gestasi
Lebih Bulan / Cukup Bulan / Kurang Bulan
Keadaan Bayi
Berat lahir
Panjang
Lingkar Kepala
Langsung menangis
Pucat Biru Kuning
Kejang
Kemerahan
Nilai Apgar
Kelainan Bawaan
Kesimpulan Riwayat kehamilan / kelahiran : .....................................................................
RIWAYAT PERKEMBANGAN
Pertumbuhan Gigi
: .............. bulan
Psikomotor
Tengkurap
Duduk
Berdiri

: .............. bulan
: .............. bulan
: .............. bulan

Berjalan
: .............. bulan
Bicara
: .............. bulan
Membaca & Menulis : ...... bulan

Perkembangan Pubertas
Rambut pubis
: .............. tahun
Payudara
: .............. tahun
Menarche
: .............. tahun
Gangguan Perkembangan Mental / Emosi
Bila ada, Jelaskan ...........................................................................................................
Kesimpulan Riwayat Perkembangan .............................................................................

RIWAYAT MAKANAN
Umur (bulan)
0-2
2-4
4-6
6-8
8-10
10-12

ASI / PASI

Buah / Biskuit

Bubur Susu

Nasi Tim

Umur diatas 1 tahun


Jenis Makanan
Nasi / Pengganti
Sayur
Daging
Telur
Ikan
Tahu
Tempe
Susu (merk/tambahan)
Lain-lain

Frekuensi dan Jumlah

Kesulitan makan : + / Bila ada, ..............................................................................................................................


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Kesimpulan Riwayat Makanan : ........................................................................................
RIWAYAT IMUNISASI
Vaksin
BCG
DPT/DT
POLIO
CAMPAK
HEPATITIS B
MMR
TIPA

Dasar ( umur )
x
x
x

Ulangan (umur)

Kesimpulan Riwayat Imunisasi : ........................................................................................

RIWAYAT KELUARGA
a. Corak Reproduksi
No

Tgl. Lahir
(umur)

Jenis
Hidup
Kelamin

Lahir
Mati

Abortus

Mati
(sebab)

Keterangan
Kesehatan

1
2
3
4
5
b. Riwayat Pernikahan
Ayah / Wali

Ibu / Wali

Nama
Perkawinan ke Umur saat menikah
Pendidikan terakhir
(Tamat --> kelas / tingkat)
Agama
Suku Bangsa
Keadaan Kesehatan
Kosanguinitas
Penyakit, bila ada
Kesimpulan Riwayat Keluarga : .........................................................................................
c. Riwayat keluarga orang tua pasien : .......................................................................
.................................................................................................................................
d. Riwayat anggota keluarga lain yang serumah : ......................................................
.................................................................................................................................
RIWAYAT LINGKUNGAN PERUMAHAN :
Perumahan : Milik Sendiri

Menyewa

Menumpang

..................................................................................................................
Keadaan rumah : .........................................................................................
.........................................................................................

Daerah/Lingkungan : .......................................................................................................
Kesimpulan riwayat lingkungan perumahan : ....................................................................
RIWAYAT PENYAKIT YANG PERNAH DIDERITA
Penyakit
Alergi
Cacingan
Demam
berdarah
Demam
tifoid
Otitis
Parotitis

Umur

Penyakit
Difteri
Diare
Kejang
Kecelakaan,
.............................
Morbili
Operasi,
.............................

Umur

Penyakit
Penyakit jantung
Penyakit ginjal
Penyakit darah

Umur

Radang paru
Tuberkulosis
Lain,
..................................

Kesimpulan Riwayat Penyakit yang Pernah Diderita :


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PEMERIKSAAN FISIK
( Tanggal : ........................................ , Pukul : .............................. )
Keadaan Umum :
Keadaan Lain

Data Antropometri
Berat badan

: ............ kg

Tinggi badan : ............ cm

Lingkar kepala

: ............ cm

Lingkar dada

: ............ cm

Lingkar lengan atas : ............ cm


Status Gizi
BB/U :
TB/U :
BB/TB :
Kesan Gizi :

Tanda Vital
Frekuensi nadi : ............ x/menit

Frekuensi napas

: ............ x/menit

Tekanan darah : ............ mmHg

Suhu tubuh

: ............ oC

Status Generalis
Kepala

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

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Wajah

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Rambut

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Mata

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Telinga

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Hidung

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Bibir

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Mulut

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Lidah

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Tonsil

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Tenggorokan

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Leher

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Thorax

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Jantung

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Paru

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Abdomen

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Genitalia

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Kelenjar Getah Bening

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Anggota Gerak

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Tulang Belakang

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Susunan Saraf

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Kulit

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PEMERIKSAAN LABORATORIUM
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RINGKASAN
(Anamnesis, Pemeriksaan fisik, dan Pemeriksaan penunjang)
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DIAGNOSIS BANDING :
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DIAGNOSIS KERJA

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ANJURAN PEMERIKSAAN PENUNJANG :
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PENATALAKSANAAN :
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PROGNOSIS :

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