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MR.

3A-I/MATA/RI/2015

RSK. Dr. Tadjuddin Chalid Makassar


Jl. Pajjaiang/Paccerakkang No 67 Daya Makassar
Telp. (0411) 512902, Faksimile : (0411) 511011

PENGKAJIAN AWAL RAWAT INAP MEDIS


MATA

Ruangan : Tanggal : Jam:

No. Rekam Medik : ..................................................................................................................................................


Nama Lengkap : ..................................................................................................................................................
Tanggal Lahir : ..................................................................................................................................................L / P

Rujukan : Ya, dari, RS ....................... Puskesmas ........................ Dr. .............................. Lainnya.............................


Diagnosa Rujukan .............................................................................................................................................................................
Tidak Datang Sendiri Diantar …………………………………………………..….

Riwayat Alergi : Tidak Ada Ada, Sebutkan 1. …………………………………………………………….…………………....


2. …………………………………………………………….……………………
3. …………………………………………………………….……………………

Dokter yang Memeriksa : .........................................................................................................................................

ANAMNESA
1. Keluhan Utama: ......................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
2. Keluhan Tambahan: ................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
3. Anamnesis Terpimpin................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
4. Riwayat Penyakit dahulu / Faktor Resiko:

Hipertensi DM PJK Asma Stroke Liver Ginjal TB Paru Rokok


Minum Alkohol Lain-lain ………………………………………………

Pernah dirawat Tidak Ya, Kapan ……………………. Di mana …………..………………. Diagnosis …………………………..

5. Riwayat Pengobatan(Termasuk obat yang sedang dikonsumsi) :

Nama Obat Dosis Waktu Penggunaan


1. ………………………………………. ………………….…………………. ………………………………………
2. ………………………………………. …………………………………….. ………………………………………
3. …………………………………........ ………………….…......………….. ………………………………………
4. …………………………………….… ………………………………..…… .………………………………………

6. Riwayat Penyakit Keluarga

Hipertensi Kencing Manis Jantung Asma Lainnya …………………………………………………


PENILAIAN NYERI

Nyeri : Tidak Ya: Lokasi: …………….……. Intensitas (0-10) ……


Jenis : Akut Kronis Skor : ……...… (Metode VAS/BPS/NIPS/FLACC)
TANDA-TANDA VITAL

KeadaanUmum: Baik Sedang Lemah Jelek, Gizi: Baik Kurang Buruk


GCS: E….... M….... V….…. Tindakan Resusitasi: Ya Tidak
BB : …………… Kg TB:………….… cm
Tensi: …………. mmHg, Nadi: …………. x/mnt
Respirasi: …….. x/mnt, Suhu Axila/Rektal: ………… OC/……………. OC

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MR.3A-II/MATA/RI/2015

RSK. Dr. Tadjuddin Chalid Makassar


Jl. Pajjaiang/Paccerakkang No 67 Daya Makassar
Telp. (0411) 512902, Faksimile : (0411) 511011

PENGKAJIAN AWAL RAWAT INAP MEDIS


MATA

PEMERIKSAAN UMUM :

OCULUS SINISTER
OCULUS DEXTER
VISUS ………………………….
……………………………….
KOREKSI ………………………….
……………………………….
SKIASCOPI ………………………….
……………………………….
SENSUS COLORIS ………………………….
……………………………….
BULBUS ACOLI ………………………….
……………………………….
PARESE / PARALYSE ………………………….
……………………………….
SUPERCILIA ………………………….
……………………………….
PALPEBRA SUPERIOR ………………………….
……………………………….
PALPEBRA INFERIOR ………………………….
……………………………….
CONJUNCTIVA PALPEBRALIS ………………………….
……………………………….
CONJUNCTIVA FORNICES ………………………….
……………………………….
CONJUNCTIVA BULBI ………………………….
……………………………….
SCLERA ………………………….
……………………………….
CORNEA ………………………….
……………………………….
CAMERA OCULI ANTERIOR ………………………….
……………………………….
IRIS ………………………….
……………………………….
PUPIL ………………………….
……………………………….
LENSA ………………………….
……………………………….
FUNDUS REFLEKS ………………………….
……………………………….
CORPUS VITREUM ………………………….
……………………………….
TENSIO OCULI ………………………….
……………………………….
SYSTIM CANALIS LACRIMALIS ………………………….
……………………………….
LAIN – LAIN ………………………….
……………………………….

PEMERIKSAAN KHUSUS ( Funduscopi Campus Visi, Tonometri, dll)

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MR.3A-III/MATA/RI/2015

RSK. Dr. Tadjuddin Chalid Makassar


Jl. Pajjaiang/Paccerakkang No 67 Daya Makassar
Telp. (0411) 512902, Faksimile : (0411) 511011

PENGKAJIAN AWAL RAWAT INAP MEDIS


MATA

STATUS OFTALMOLOGIS Nama : Nomor RM :


(Lanjutan) TanggalLahir : Ruang:

RINGKASAN :

DIAGNOSA DIFERENSIAL

KESAN / DIAGNOSA KERJA

Dokter :Nama :……………………………………….

Tanda tangan :……………………………….

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