STATUS PASIEN BAGIAN ILMU PENYAKIT MATA

P3D FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM BANDUNG

NAMA : UMUR:
ANAMNESA RUANGAN : NO RM:
TANGGAL :
- KELUHAN UTAMA

- ANAMNESA KHUSUS

- RIWAYAT PENYAKIT DAHULU

- RIWAYAT GIZI

- KEADAAN SOSIAL EKONOMI

- PENYAKIT SISTEMIK
 TRACT RESPIRASI
 TRACT DIGESTIVE
 CARDIO VASKULAR
 ENDOKRINE
 NEUROLOGY
 KULIT
 THT
 GIGI DAN MULUT
 LAIN-LAIN
I. PEMERIKSAAN UMUM
- TINGGI BADAN :........………………………………………………………………………………...
- BERAT BADAN : ……………………………………………………………………………………..
- TEKANAN DARAH : ……………………………………………………………………………………..
- NADI : ……………………………………………………………………………………..
- SUHU : ……………………………………………………………………………………..
- PERNAFASAN : ……………………………………………………………………………………..
- CARDIO VASCULAR : ……………………………………………………………………………………..
- G.I. TRACT : ……………………………………………………………………………………..
- PARU-PARU : ……………………………………………………………………………………..
- NEUROLOGY : ……………………………………………………………………………………..
II. PEMERIKSAAN VISUS DAN REFRAKSI
- VISUS : SC : ……….……….……PH :……..…..….. ……….……….……PH : ..…..…..
CC : ……….……….………………..…..….. ……….……….………………..…..
STEN : ……….……….………………..…..….. ……….……….………………..…..

- KOREKSI : S........... C………. as………. S........... C………. as……….

Add:S……….……….……………… Add: S……….……….………………..

- MUSCLE BALANCE : ……….……….………………..….. ……….……….………………..…..

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- PERGERAKAN BOLA MATA :……….……….………………..….. ……….……….………………..…..
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III.PEMERIKSAAN EKSTERNAL

- PALPEBRA SUPERIOR : ……….……….………………..….. ……….……….………………..…..

- PALPEBRA INFERIOR : ……….……….………………..….. ……….……….………………..…..
- CILIA : ……….……….………………..….. ……….……….………………..…..
- AP. LACRIMALIS : ……….……….………………..….. ……….……….………………..…..
- CONJ. TARS. SUPERIOR : ……….……….………………..….. ……….……….………………..…..
- CONJ. TARS. INFERIOR : ……….……….………………..….. ……….……….………………..…..
- CONJ. BULBI : ……….……….………………..….. ……….……….………………..…..
- CORNEA : ……….……….………………..….. ……….……….………………..…..
- KAMAR DEPAN : ……….……….………………..….. ……….……….………………..…..
- PUPIL : ……….……….………………..….. ……….……….………………..…..
- DIAMETER : ……….……….………………..….. ……….……….………………..…..
- REFLEX CAHAYA : ……….……….………………..….. ……….……….………………..…..
Direct : ……….……….………………..….. ……….……….………………..…..
Konsensuil : ……….……….………………..….. ……….……….………………..…..
- IRIS : ……….……….………………..….. ……….……….………………..…..
- LENSA : ……….……….………………..….. ……….……….………………..…..
- LAIN-LAIN : ……….……….………………..….. ……….……….………………..…..
IV. PEMERIKSAAN SLIT LAMP DAN BIOMICROSCOPY
- CILIA : ……….……….………………..….. ……….……….………………..…..
- CONJUNCTIVA : ……….……….………………..….. ……….……….………………..…..
- CORNEA : ……….……….………………..….. ……….……….………………..…..
- KAMAR DEPAN : ……….……….………………..….. ……….……….………………..…..
- IRIS : ……….……….………………..….. ……….……….………………..…..
- LENSA : ……….……….………………..….. ……….……….………………..…..
V. TONOMETRI
- PALPASI : ……….……….………………..….. ……….……….………………..…..
- SCHIOTZ : ……….……….………………..….. ……….……….………………..…..
VI. GONIOSCOPY : ……….……….………………..….. ……….……….………………..…..
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VII. VISUAL FIELD : ……….……….………………..….. ……….……….………………..…..
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VIII. PEMERIKSAAN PADA KEADAAN MIDRIASIS
- FUNDUSKOPI MEDIA……….……………..….. MEDIA….………………..…..
- PAPIL
- A/V RATIO :
- C/D RATIO:
- RETINA:
- MACULA :

IX. PEMERIKSAAN LAIN-LAIN

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X. RESUME:
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XI. DIAGNOSIS KERJA : ……………………………………………………………………………………..

XII. DIFFERENSIAL DIAGNOSIS

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XIII. RENCANA PEMERIKSAAN : ……………………………………………………………………………………..
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XIV. RENCANA THERAPY : ……………………………………………………………………………………..
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XV. RENCANA OPERASI : ……………………………………………………………………………………..
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XVI. PROGNOSA : ……………………………………………………………………………………..
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NAMA KOAS :

NPM :

KEGIATAN :

PRESEPTOR :