FAKULTAS KEDOKTERAN UNIVERSITAS MUSLIM INDONESIA

Bagian Ilmu Kesehatan Kulit dan Kelamin FK UMI/RS. Ibnu Sina

STATUS PENDERITA

DIAGNOSIS :..

NAMA : ...............
NIM :..
PEMBIMBING :..
1. Nama : ........................................................................................
Umur : ........................................................................................
Alamat : ........................................................................................
Status Perkawinan : ........................................................................................
Tgl Masuk RS Poli : ........................................................................................

2. Anamnesis : Autoanamnesis / Heteroanamnesis

Keluhan Utama : ........................................................................................
Anamnesis Terpimpin : ........................................................................................
..........................................................................................
.............................................................................................
..........................................................................................
.. ........................................................................................
..................................................................................
..........................................................................................
.. ........................................................................................
. ......................................................................
.. ..................................................................
.................................................................
. ................................................................
. ......................................................................

3. Status Presents
Keadaan Umum : Sakit (ringan/ sedang /berat) ; Kesadaran :..
: Gizi (kurang /cukup/baik); Higiene (buruk/sedang/baik)
: Tensi.mmHg; Nadix/mnt
Pernafasanx/mnt; SuhuC
Jantung / Paru : ........................................................................................
Abdomen : ........................................................................................
Ekstremitas : ........................................................................................
Kelenjar Limfe : ........................................................................................
4. Status Lokasi : Kepala, Dada, Punggung, Bokong, Genitalia, Ekstremitas
(superior, inferior)

5. Status Dermatologi Venereologi

Lokasi : ........................................................................................
Ukuran : ........................................................................................
Effloresensi : ........................................................................................

6. Laboratorium
Kerokan : ........................................................................................
..........................................................................................
Dan lain-lain : ........................................................................................
..........................................................................................

7. Resume : ........................................................................................
...............................................................................
. ......................................................................................
............................................................................
. ......................................................................
.. ..........................................................................
.................................................................
............................................................
....................................................
.......................................................
. ........................................................
.................................................................
.. ..........................................................
.. ...............................................
8. Diagnosis Banding : ........................................................................................
.........................................................................................
9. Diagnosis : ........................................................................................

10.Diskusi : ........................................................................................
...............................................................................
. ......................................................................................
............................................................................
. ......................................................................
.. ..........................................................................
.................................................................
............................................................
....................................................
.......................................................
. ........................................................
.................................................................
.. ..........................................................
.. ...............................................

11.Anjuran Pemeriksaan : ........................................................................................

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

12.Terapi Sistemik : ........................................................................................

..........................................................................................
..........................................................................................
..........................................................................................
Topikal : ........................................................................................
..........................................................................................

13. Prognosis : ........................................................................................