STATUS PASIEN

1. Identitas
Nama
Tgl. Lahir/Umur
Jenis Kelamin
Alamat
Tgl. Masuk RS
Identitas Orang Tua

:_________________________________________
:_________________________________________
:_________________________________________
:_________________________________________
:_________________________________________
Ayah

Ibu

Nama
Umur
Pendidikan terakhir
Pekerjaan
2. Anamnesis
a. Keluhan Utama :_________________________________________
b. Riwayat Penyakit Sekarang:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
c. Riwayat Penyakit Dahulu:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
d. Riwayat Penyakit Keluarga:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
e. Genogram:

f. Riwayat Kehamilan dan Persalinan:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
g. Riwayat Makan:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
h. Riwayat Imunisasi:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
________________________________________________________
i. Riwayat Tumbuh-Kembang:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

_________________________________________________________
________________________________________________________
j. Riwayat sosioekonomi dan Lingkungan:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
3. Anamnesis Sistem
a. SSP
:_________________________________________
b. Kardiovaskuler :_________________________________________
c. Respirasi
:_________________________________________
d. Gastrointestinal :_________________________________________
e. Genitourinaria :_________________________________________
f. Muskuloskeletal :_________________________________________
g. Integumen
:_________________________________________
h. Termoregulasi :_________________________________________
4. Pemeriksaan Fisik
Kesan umum

: _________________________________________

Antopometri
BB
:
TB/PB :
LLA :
LK
:

BB/U:
TB/U:
BB/PB:

Tanda-tanda Vital
a. Nadi
:_______________________________________________
b. Suhu
:_______________________________________________
c. TD
:_______________________________________________
d. Respirasi :_______________________________________________
Status generalisata

a.
b.
c.
d.
e.
f.
g.

Kepala
: normocephal/macrocephal/microcephal
Mata
: Konjungtiva anemis (__), sklera ikterik (__),
Telinga
: Simetris, sekret (_/_), nyeri tekan (_/_)
Hidung
: deviasi septum (__), nyeri tekan (__), sekret (__).
Tenggorokan : tonsil (T_/T_), hiperemis (__), dedritus (__)
Leher
: Pembesaran KGB (__), Nyeri Tekan (__), JVP (__)
Paru
:
Inpeksi
: simetris (_), retraksi (_)
Palpasi
:fremitus taktil kanan (___) kiri
Perkusi
: sonor (__)________________________________
Auskultasi
: SND vesikuler, Ronki (__/__), Wheezing (__/__)
h. Jantung
:
Inspeksi
: ictus codis tidak terlihat
Palpasi
: IC teraba di SIC V linea midklavikula sinistra
Perkusi
: batas jantung normal
Auskultasi
: S1 tunggal, S2 split tak konstan, reguler, gallop
(__), murmur (__)
i. Abdomen
:
Inspeksi
: Distensi (__), keras seperti papan (__)
Auskultasi
: Bising usus (__) normal
Perkusi
: _________________________________________
Palpasi
: hepar (_) dan lien (_)________________________
j. Ekstremitas
: sianosis (_), edema (_), akral dingin (_),
CRT___2,
5. Pemeriksaan Penunjang
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
6. Diagnosis:

7. Diagnosis Banding:
____________________________________________________________
___________________________________________________________
____________________________________________________________
___________________________________________________________
8. Tatalaksana:
Medikamentosa

Nonmedikamentosa

9. Prognosis