RS.

SIDO WARAS
Jl. Raya Pasar Sawahan Km.10
Kec Bangsal, Kab. Mojokerto
Telp. 0321-598623 Fax : 0321-598624 / 0321-590620 STIKER IDENTITAS
Emergency Call : 0321-598999
e_mail : rs.sidowaras@yahoo.com
ASESMEN MEDIS KARDIOLOGI DAN
KEDOKTERAN VASKULER
Ruangan : ............................................................................. Tanggal :.................. Jam : .......................
ALERGI TERHADAP :
ANAMNESIS
1. Keluhan Utama :

2. Riwayat Penyakit Sekarang :

3.Riwayat Penyakit Dahulu :

Hipetensi Kencing Manis Jantung Lain-lain .................................
4. Riwayat Pengobatan :
Nama Obat Dosis Lamanya
a. ....................................................... ....................................... .....................................................
b. ....................................................... ....................................... .....................................................
c. ........................................................ ....................................... .....................................................
5. Riwayat Penyakit Keluarga :
Hipetensi Kencing Manis Jantung Lain-lain .................................
6. Riwayat Sosial :
Merokok Minum Alkohol Lain-lain ......................................................................
PEMERIKSAAN FISIK
1. Tanda-tanda vital
Keadaan umum :.......................................................
Kesadaran : Compos Mentis Apatis Sporo Coma Coma Sulit Dinilai
GCS : E.........M........ V.......
Tensi : .........mmHg, Suhu :..........0c BB :..........kg TB :..........cm Gizi : .............................
Nadi : ......... x/mnt Respirasi :............. x/mnt Saturasi Oksigen :............%

2. Pemeriksaan Umum :
Kepala : Conjunctiva : Anemis
Normal, Sklera : Icteric Normal, Cyanosis : Ya Tidak
Odema palpebrae : Ya Tidak, Pupil : Isocore Anisocore, Myosis Midriasis
Leher : JVP.................................... Pembesaran Kelenjar............................ Thyroid :...................................
Thorax : Simetris / Asimetris .......................................................................................................................................
Jantung : Inspeksi : - Iktus Kordis : Normal Melebar : ke...........................................................
Lokasi : .............................................................................................................................
- Pulsasi : Apec Prekordium Epigastrium
Lainnya : .............................................................................................................................
Palpasi : - Iktus Kordis : Normal Kuat angkat Meluas
Lokasi : ..................................................................................................................
-Thrill : Sistolik Diastolik
Lokasi : ..................................................................................................................
Perkusi : - Batas Atas :...................................................................................................................
Bawah :...................................................................................................................
Kanan :...................................................................................................................
Kiri :...................................................................................................................
Auskultasi : - Suara Jantung Utama : S1..................S2.................. Reguler Ireguler
- Extra systole :+/-
- Gallop :+/-
- Suara jantung tambahan :
1. Murmur :
- Fase : Sistolik Diastolik Lainnya : ...........................
- Lokasi : Apex ICS II Kiri PSL Kiri ICS II Kanan PSL Kanan
ICS IV PSL Kiri Lainnya : ...........................
- Kualitas : Rumbling Blowing Ejection
 Lainnya : ...................................................................................

- Grade :I II III IV V VI
- Penjalaran : Axilla Punggung Sekitarnya
Lainnya :...................................................................................
2. Opening Snap : + / -
3. Fiction Rub :+/-
Pulmo : Suara nafas : .................................. Ronchi....................................... Wheezing.............................
Abdomen : Hepar : Normal Teraba : .................. jari bpx,
Lien : Normal Teraba : Schufner : ...............................................................
Ascites : Negatif Minimal permagma
Extremitas : Normal : Hangat Dingin, Odema : Tidak Ya, Lokasi : ....................
Jari tabuh : Tidak Ya.......... Hemiparese/Plegia : Kanan Kiri
HASIL PEMERIKSAAN PENUNJANG

DIAGNOSIS (ICD-X)

RENCANA KERJA (CARE OF PLAN)

EDUKASI
 Dokter Pengkaji, DPJP,

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