STATUS PASIEN KARDIOLOGI

I. ANAMNESIS

Identitas

Nama : ...............................................................................................................

Jenis Kelamin : ...............................................................................................................

Umur : ...............................................................................................................

Alamat : ...............................................................................................................

Pekerjaan : ...............................................................................................................

Tanggal Masuk RS : ...............................................................................................................

Anamnesis dilakukan pada tanggal ................................................pukul.........................WIB

Keluhan Utama

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Riwayat Penyakit Sekarang

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Riwayat Penyakit Dahulu

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Riwayat Penyakit Keluarga

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Riwayat Sosial Ekonomi

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II. PEMERIKSAAN FISIK

Pemeriksaan dilakukan pada tanggal ................................................pukul.....................WIB

Status Generalis

Keadaan umum : ...............................................................................................................

Keadaan sakit : ...............................................................................................................

Kesadaran : .................................................................................... GCS : E M V

Tanda vital

- Nadi : ............... kali/menit, irama ............................

- Tekanan darah : ............../............ mmHg

- Napas : ................. kali/menit

- Suhu : ...........°C

Kulit : warna kulit............................., sianosis ( ), dekubitus ( )

Kepala : bentuk...................................., simetris/tidak, nyeri tekan ( )

Mata : konjungtiva anemis ( / ), sklera ikterik ( / )

Telinga : sekret ( )

Hidung : sekret ( ), deviasi septum ( )

Mulut : bibir sianosis ( ), lidah kotor ( ), tonsil T /T

Leher : pembesaran limfonodi ( ), kaku kuduk ( ), deviasi trakea ( ),

pembesaran tiroid ( ), tekanan JVP ................cmH2O, refluks

hepatojugular ( )

Paru

- Inspeksi : statis : ................................................................................................

dinamis : ................................................................................................

- Palpasi : stem fremitus .......................................................................................

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 - Perkusi : ................................................................................................................

- Auskultasi : suara napas dasar ..................................., ronki ( )

wheezing ( )

Abdomen

- Inspeksi : bentuk................................................., venektasi ( )

- Palpasi : nyeri tekan ( ) di regio , lien ...........................................

hepar ......................................................................................................

- Perkusi : ............................, asites ( )

- Auskultasi : bising usus .............................................................................................

Ekstremitas : oedema ( / ), sianosis ( ) jari tabuh ( ), tremor ( ),

akral ....................., capillary refill time ................................................

Status Lokalis,

Jantung

- Inspeksi : iktus kordis ............................................................................................

- Palpasi : iktus kordis teraba di .............................................................................

thrill ( )

- Perkusi : batas jantung atas di ..............................................................................

batas jantung bawah di ..........................................................................

batas jantung kanan di ...........................................................................

batas jantung bawah di ..........................................................................

- Auskultasi : bunyi jantung S1S2 ............................, murmur ( ) sistolik / diastolik

derajat ....../......., terdengar di ..............................................................

gallop ( )

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III. PEMERIKSAAN PENUNJANG

Laboratorium (hasil pemeriksaan tanggal )

Hb : ........................................... Troponin I : ........................................

Ht : ........................................... SGOT : ........................................

Leukosit : ........................................... SGPT : ........................................

Trombosit : ........................................... Kolesterol total : ........................................

GDS : ........................................... HDL kolesterol : ........................................

Ureum : ........................................... Trigliserida : ........................................

Kreatinin : ........................................... CKMB : ........................................

EKG (hasil pemeriksaan tanggal...........................................)

Deskripsi :

 Frekuensi : .............. kali/menit

 Irama jantung : ....................................................................................................

 Gelombang P : ....................................................................................................

 Interval PR : ....................................................................................................

 Kompleks QRS : ....................................................................................................

 Aksis jantung : ...................................................................................................

 Segmen ST : ...................................................................................................

 Gelombang T : ...................................................................................................

 Lainnya : ...................................................................................................

Kesimpulan

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IV. RESUME

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V. DIAGNOSIS

Diagnosis fungsional : ...................................................................................................

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Diagnosis anatomi : ...................................................................................................

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Diagnosis etiologi : ...................................................................................................

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VI. TATALAKSANA

Non Medikamentosa :

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 Medikamentosa :

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Usulan Pemeriksaan Lanjutan

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VII. PROGNOSIS

Ad vitam : ................................................................................................................

Ad functionam : ................................................................................................................

Ad sanactionam : ................................................................................................................