STATUS PEDIATRIK

I. Identitias Pasien
No. RM : 54-89-31
Nama pasien : An. NS
Usia : 7 tahun 2 bulan
Jenis kelamin : Perempuan
Agama : Islam
Alamat : Desa Lingkis, Kecamatan Jejawi, Ogan Komering Ilir
MRS : 1 Januari 2018
II. Anamnesis
a. Keluhan Utama
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b. Riwayat Perjalanan Penyakit

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c. Riwayat Penyakit Dahulu
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d. Riwayat Penyakit dalam Keluarga

Hipertensi ( ) Asma ( )
TB paru ( ) Kejang ( )
Diabetes ( )

e. Riwayat Pengobatan
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f. Riwayat Imunisasi
BCG :
Polio :
Hb :
DPT :
Campak :

g. Riwayat Persalinan
Normal ( ) Vacum ( ) Forcep ( ) Sc ( )
Ditolong oleh : Dokter ( ) Bidan ( )
BB ( ) PB ( ) LK ( )
Keadaan saat lahir: segera menangis ( ) Tidak segera menangis (
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h. Riwayat Nutrisi
ASI : ( ) eksklusif ..... bulan ( ) durasi ..... bulan ( )
frenkuensi ..... x/hari
Susu formula : ( ) sejak usia ..... bulan ( ) frekuensi ..... x/hari
Bubur susu : ( ) sejak usia ..... bulan ( ) frekuensi ..... x/hari
 Nasi tim : ( ) sejak usia ..... bulan ( ) frekuensi ..... x/hari
Makanan dewasa : ( ) sejak usia ..... bulan ( ) frekuensi ..... x/hari

i. Riwayat Tumbuh Kembang

( ) Menegakkan kepala ..... bulan
( ) Membalik badan ..... bulan
( ) Duduk ..... bulan
( ) Merangkak ..... bulan
( ) Berdiri ..... bulan
( ) Berjalan ..... bulan
( ) Berbicara ..... bulan

III. Pemeriksaan Fisik

a. Tanda Vital
Keadaan Umum :
Kesadaran :
TD :
Nadi :
Temp :
Respirasi :
SPO2 :
BB :
PB :
BB/U :
PB(TB)/U :
BB/TB :

b. Pemeriksaan Umum
Kepala : ( ) Normal ( ) Mikrosefali ( ) Makrosefali
Mata : Konjungtiva anemis ( / ), Sklera ikteri ( / ),
Sekret
 ( / ), Cekung ( / ), Pupil isokor ( / ), Reflek
cahaya ( / ), Edema ( / )
THT : Telinga ..............., Hidung .............., Tenggorokan
..............., Tonsil ..............., Lidah ..............., Bibir
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Leher : JVP ..............., Perbesaran kelenjar ...............
Thoraks : Simetris ( ) Retraksi ( )
Cor : S1,S2..............., murmur ( ), gallop ( )
Pulmo : Suara napas ..............., Wheezing ( ), Ronkhi ( )
Abdomen :
Nyeri tekan ( ), Meteorismus ( ), Peristaltik
..............., Turgor ..............., Asites ( )
Hepar :
Lien :
Massa :
Ekstremitas : ( ) Hangat/Dingin ( ), Edema ( ), CRT .....

IV. Pemeriksaan Penunjang

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V. Diagnosis Banding
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VI. Diagnosis Kerja

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VII. Tatalaksana
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VIII. Prognosis
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IX. Edukasi
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