UNIVERSITAS CENDERAWASIH

FAKULTAS KEDOKTERAN
SMF MATA RUMAH SAKIT UMUM DAERAH JAYAPURA
Jln. Kesehatan No. I Telp (0967)-533616 Fax. (0967)-533616

STATUS PEMERIKSAAN PASIEN MATA

I. IDENTITAS
Nama :
Umur :
Jenis Kelamin :
Alamat :
Pendidikan :
Pekerjaan :
Tanggal Pemeriksaan :
No. Rekam Medik :

II. ANAMNESIS
Keluhan Utama :
Riwayat Penyakit :
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III. PEMERIKSAAN FISIS UMUM
1. Status Generalisata
Keadaan Umum :
Kesadaran :
Tekanan Darah :
Nadi :
Suhu Badan :
Jantung dan Paru :
Abdomen :

2. Status Neurologis
Motorik :
Sensorik :
Refleks :
Kesan/kesimpulan :

3. Status Psikiatri
Afek :
Sikap :
Respon :
Kesan/Kesimpulan :

IV. PEMERIKSAAN KHUSUS/STATUS OFTALMOLOGIS

1. Pemeriksaan Subyektif
JENIS PEMERIKSAAN OD OS
Form Sence Sentral Distance vision
(Snellen Card)
Near Vision
(Jaeger Test)
Perifer
Colour Sence
Light Sence
Light Projection

2. Pemeriksaan Objektif
a. Penanganan Bagian Luar
JENIS PEMERIKSAAN OD OS
Inspeksi Edema
umum Hiperemis
Sekret
Lakrimasi
Fotofobia
Blefarospasme
Posisi bola mata
Benjolan/tonjolan
Supersilia
 Palpebra Posisi
Warna
Bentuk
Edema
Pergerakan
Ulkus
Tumor
Lain-lain
Margo Posisi
palpebra Ulkus
Krusta
Silia
Skuama
konjungtiva Palpebra Warna
Sekret
Edema
Bulbi Warna
Benjolam
Pembuluh darah
Injeksi

JENIS PEMERIKSAAN
Forniks
Konjungtiva Posisi
Gerakan
Warna
Sklera Perdarahan
Benjolan
Lain-lain
Kekeruhan
Ulkus
Inspeksi Sikatriks
Khusus Kornea Panus
Bulbus Okuli Arkus Senilis
Permukaan
Refleks Kornea
Lain-lain
COA
Perlekatan
Iris Warna
Lain-lain
Pupil Bentuk
Refleks
Lensa Kekeruhan
Nyeri Tekan
Palpasi Tumor
TIO Digital
 b. Pemeriksaan Kamar Gelap

JENIS PEMERIKSAAN OD OS
Obligus Iluminatum Kornea
COA
Iris
JENIS PEMERIKSAAN OD OS
Obligus Iluminatum
Kornea
COA
Direct Ophtalmoscope
Lensa
Badan Kaca
Refleks Fundus
Pembuluh Darah
Macula Lutea
Kornea
COA
Slit Lamp Iris
Lensa
Konjungtiva Bulbi
Tensi Oculi Schiotz
Placido Test
Pupil Distance (PD)

V. RESUME
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VI. DIAGNOSIS BANDING

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VII. DIAGNOSIS KERJA

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VIII. TERAPI
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IX. PROGNOSIS

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X. ANJURAN PEMERIKSAAN

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COASS

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