FAKULTAS KEDOKTERAN UMP/

RS UMUM DAERAH PALEMBANG BARI

REKAM MEDIK KEPANITERAAN KLINIK

IDENTIFIKASI
Nama Lengkap : ................................. No. Reg. RS : .................................
Jenis Kelamin : ................................. Tgl Pemeriksaan : .................................
Tgl Lahir/Umur : ................................. Ruang : .................................
Alamat : ................................. Dokter Pemeriksa : .................................
Pekerjaan : ................................. Co.asisten : .................................
Agama : ................................. MRS Tanggal : .................................

ANAMNESA
Keluhan utama oleh penderita/keluarga/orang yang berhubungan dengan penderita

Riwayat Perjalanan Penyakit

1
Riwayat Penyakit yang Pernah Diderita

 Cacar Air  Hepatitis  Psikosis

 Tuberculosis  Kencing Manis  Demam Rematik
 Batu Empedu  Campak  Hipertensi
 Cacar  Thypus Abdominalis  Neurosis
 Malaria  Tumor  Pneumonia
 Batu Ginjal  Influenza  Ulkus Peptikum
 Difteria  Scrofuloderma  Pleuritis
 Disentri  CVA  Gastritis
 Burut  Cholera  Lain-lain
 Batuk  Syphilis

Riwayat Keluarga Riwayat Penyakit Dalam Keluarga

Ya/ Hub. dg
Penyakit
Tidak Keluarga
Alergi
Asthma
Arthritis
Diabetes
Jantung
Ginjal
Hipertensi
Kanker
Lambung
Rheumatic
Syphilis
Epilepsy
Sakit Jiwa
Bunuh diri
Tuberculosis
Lain-lain

2
Nama/Umur/Jenis Kelamin : ........................................ Ruangan : .....................

RIWAYAT HIDUP

TEMPAT LAHIR
Rumah : .............................Rumah Bersalin : .............................RS : .............................

PARTUS
Spontan : ........................ Tindakan Khusus : ........................ Tdk Ketahui : ........................

MASA KANAK-KANAK (Peristiwa Penting)

....................................................................................................................................................................

SIKAP TERHADAP
Ayah : ............................. Ibu : ............................. Saudara : .............................

PENDIDIKAN
SD : ............................. SMP : ............................. SMA : .............................

PEKERJAAN :
Bidang Kantor : ............................. Industri : ............................. Lain-lain : .............................

PERKAWINAN
Lama Perkawinan sekarang : ............................. Jumlah Perkawinan : .............................
Jumlah Anak : ............................. Pengaturan Perkawinan : .............................

PERUMAHAN
Rumah Sendiri : ............................. Beli : .............................
Kontrak/Sewa : ............................. Kantor : .............................

KEBIASAAN
Merokok : ............................. Jamu : ............................. Olahraga : .............................
Kopi : ............................ Minuman keras : .............................Rekreasi : .............................
Teh : ............................. Obat-obatan : ............................. Lain-lain : .............................

TIDUR
Berapa jam : ............................. Teratur/tidak : .............................

GIZI
Berapa kali makan : ............................. Nafsu Makan : .............................
Banyaknya : ............................. Pencernaan : .............................
Teratur/tidak : ............................. Komposisi : .............................
Variasi (perinci) : .............................

KESULITAN
Keuangan : ......................................... Pekerjaan : ...................................
Keluarga : ......................................... Lain-lain : ...................................
 Catatan keluhan tambahan positif
Keluhan Organ
disamping jenis yang bersangkutan
Kulit

Bisul Rambut
Kuku Lain-lain
Kepala

Trauma Sakit kepala

Sekret Nyeri pada sinus
Mata

Nyeri Radang
Sekret Gangguan penglihatan
Kacamata Penglihatan kurang jelas
Telinga

Nyeri Tinitus
Sekret Gangguan pendengeran
Nyeri Tekan Kehilangan pendengaran
Hidung

Trauma Pilek
Nyeri Gejala penyumbatan
Sekret Post Nasal Drip
Epistaksis Gangguan Alat pembau
Mulut

Mulut Lidah
Gusi Gangguan Mengecap
Selaput Lendir Gangguan Mengunyah
Gigi-Geligi Sekresi Lidah
Tenggorokan

Tonsillitis Nyeri Tenggorokan

Laryngitis Abses Peritonsilar
Perubahan Suara
Leher

Thyroid Adenitis
Jantung/Paru-paru

Nyeri dada Batuk

Berdebar-debar Dahak
Sesak Nafas Sianosis
Edema Serangan Asma
Orthopnue Keringat malam hari

Lambung/Usus

Rasa Kembung Wasir

Mual Mencret
Muntah Tinja berwarna
Nyeri (sifat) - Dempul
Sukar menelan - Teh
Muntah darah - Nanah
Ikterus Lain-lain

Alat Kencing/Kelamin

Disuria Ngompol
Anuria Retensi Kencing manis
Oligouria Inkontinensia
Poliuria Penyakit Prostat
Hematuria Kolik Ginjal
Kencing nanah Kolik Ureter

Katanemia

Menarche
Haid
- Haid terakhir :
- Teratur/tdk
- Lama :
- Jumlah :
- Nyeri/tdk :
Leukorrhea
Gejala Klimaterium
Sakit kepala
Lain-lain
Syaraf dan Otot

Perangai :
Ingatan :
Disposisi
Kerisauan
Gelisah :
Pusing (vertigo) :
Serangan Pingsan :
Gangguan panca indera :
Neurologis :
Kejutan :
Kejang :
Parestesi:
Ataxia :
Nyeri otot dan sendi yang menyayat:
Atropi otot :
Paresis/Paralysis :
Lain-lain

Berat badan

Berat badan rata-rata :

Berat badan tertinggi (kapan) :
Tetap/Turun/Naik
Berat badan :
Dalam waktu berapa bulan :
Berat sekarang :

Tinggi badan :
PEMERIKSAAN FISIK
KEADAAN UMUM

 Keadaan Sakit : Tidak tampak sakit/sedang sakit ringan/sedang/berat

 Kesadaran :
 Anemia :
 Sianosis :
 Dyspnoe/Orthopnoe :
 Oedema Umum :
 Dehidrasi :
 Keadaan Gizi :
 Bentuk badan/habitus :
 Kebersihan :
 Cara Berjalan :
 Cara berbaring/morbiditas :
 Umur menurut dugaan pemeriksa :
 Nadi/pulse rate :
- Frekuensi : - Tegangan :
- Irama : - Gelombang :
- Isi : - Kualitas :
 Pernafasan
- Frekuensi :
- Irama :
- Tipe :
 Berat badan : kg
 Tinggi badan : cm
0
 Tempratur : C
 Tekanan darah : mmHg

Kulit
 Warna :
 Efloresensi :
 Pigmentasi :
 Jaringan Parut :
 Turgor :
 Keringat
- Umum :
- Setempat :
 Pertumbuhan rambut :
 Lapisan Lemak :
 Ikterus :
 Lembab/kering : Lain-lain :

Kelenjar Getah Bening

 Submandibula :
 Leher :
 Subclavicula :
 Axilla :
 Anal :
 Inguinal :
PEMERIKSAAN ORGAN
1. Kepala
Bentuk : Deformasi :
Ekspresi : Perdarahan Temporal :
Simetri muka : Nyeri tekan :
Rambut : Bising :

2. Mata
Exopthalmus : Sclera :
Enopthalmus : Cornea :
Kelopak : Pupil :
Conjunctiva : Visus :
Palbebra : Gerakan :
Bulbi : Lap. Pandang :

3.Telinga
Lubang : Tophi :
Selaput : Nyeri tekan :
Pendengaran : Promastoideus :

4. Hidung
Bagian luar : Ingus :
Septum : Penyumbatan :
Selaput Lendir : Perdarahan :

5. Mulut
Bibir : Selaput lendir :
Gigi-Geligi : Pharynx :
Gusi : Tonsil :
Lidah : Bau pernafasan :

6. Leher
Kel. Getah bening : Tekanan vena :
Kel. Gondok : Kaku kuduk :
Trachea : Tumor :

7. Dada
Bentuk :
Pembuluh darah :
Buah dada :
Nyeri tekan :
Nyeri ketok :
Krepitasi :
8. Paru-paru
DEPAN
Kanan
Inspeksi : .......................................................
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Palpasi : .......................................................
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.......................................................
Perkusi : .......................................................
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.......................................................
Auskultasi : .......................................................
.......................................................
.......................................................
Paru-paru
BELAKANG
Kanan
Inspeksi : .......................................................
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Palpasi : .......................................................
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.......................................................
Perkusi : .......................................................
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Auskultasi : .......................................................
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Kiri
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9. Jantung
Inspeksi : ...........................................................................................................
...........................................................................................................
Palpasi : ...........................................................................................................
...........................................................................................................
Perkusi : ...........................................................................................................
...........................................................................................................
...........................................................................................................
...........................................................................................................
Auskultas : ...........................................................................................................
...........................................................................................................
...........................................................................................................

10. Pembuluh Darah

a. Temporalis : a. Femoralis :
a. Carotis : a. Poplitea :
a. Brachialis : a. Tibialis posterior :
a. Radialis : a. Dorsalis pedis :

11. Perut
Inspeksi : .............................................................................................
.............................................................................................
Palpasi : .............................................................................................
.............................................................................................
Perkusi : .............................................................................................
.............................................................................................
Auskultasi : .............................................................................................
Hati : .............................................................................................
.............................................................................................
Limfa : .............................................................................................
.............................................................................................
Ginjal : .............................................................................................
.............................................................................................
Lain-lain : .............................................................................................
.............................................................................................
Refleks : .............................................................................................
12. Ekstremitas
Kiri Kanan
Lengan
- Tonus : ............................................... ...............................................
- Gerakan : ............................................... ...............................................
- Kekuatan : ............................................... ...............................................
- Otot : ............................................... ...............................................
- Sendi : ............................................... ...............................................
- Lain-lain : ............................................... ...............................................

Tangan
- Warna telapak : ............................................... ...............................................
- Kuku : ............................................... ...............................................
- Tremor : ............................................... ...............................................
- Ujung Jari : ............................................... ...............................................
- Kelainan jari : ............................................... ...............................................
- Lain-lain : ............................................... ...............................................

Tungkai dan kaki

- Tonus : ............................................... ...............................................
- Gerakan : ............................................... ...............................................
- Kekuatan : ............................................... ...............................................
- Otot : ............................................... ...............................................
- Sendi : ............................................... ...............................................
- Varises : ............................................... .............................................
..
- Parut : ............................................... ...............................................
- Luka : ............................................... ...............................................
- Edema : ............................................... .............................................
..

Refleks
- Bicceps : ............................................... ...............................................
- Triceps : ............................................... .............................................
..
- Patella : ............................................... .............................................
..
- Achilles : ............................................... ...............................................
- Cremaster : ............................................... ...............................................
- Babynski : ............................................... ...............................................
- Kernig : ............................................... .............................................
..

13. Genitalia Eksterna

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NAMA : ..................................................... RUANGAN : ......................................

LABORATORIUM DAN PEMERIKSAAN TAMBAHAN

TANGGAL PEMERIKSAAN PENUNJANG KETERANGAN

TANGGAL PEMERIKSAAN PENUNJANG KETERANGAN

TANGGAL PEMERIKSAAN PENUNJANG KETERANGAN

TANGGAL PEMERIKSAAN PENUNJANG KETERANGAN

RINGKASAN
(Cerita singkat penemuan positif dan anamnesis, pemeriksaan fisik dan laboratorium yang menuju ke
diagnosa)

Nama/Umur/Jenis Kelamin :
Ruangan :

Anamnesis :

Pemeriksaan Fisik :

Laboratorium :
 Diagnosis Sementara
...........................................................................................................................
...........................................................................................................................

Diagnosis Banding
1. ..................................................................................................................
2. ..................................................................................................................
3. ..................................................................................................................
4. ..................................................................................................................
5. ..................................................................................................................

Pengobatan
1. .................................................................................................................
2. .................................................................................................................
3. .................................................................................................................
4. .................................................................................................................
5. .................................................................................................................
6. ................................................................................................................
7. ................................................................................................................
8. ................................................................................................................
9. .................................................................................................................
10. .................................................................................................................

Prognosa

Quo ad vitam : .................................................................................................

Quo ad functionan : ........................................................................................

Rencana Pemeriksaan khusus

1. .......................................................................................................................
2. .......................................................................................................................
3. .......................................................................................................................
4. .......................................................................................................................
5. .......................................................................................................................
6. .......................................................................................................................
7. .......................................................................................................................
8. .......................................................................................................................
 LEMBAR FOLLOW UP
KOAS PENYAKIT DALAM
TGL S O A P

S : Subjektif (sign + simptom)

O: Objektif (PF + pemeriksaan penunjang)
A : Assesment (kesimpulan, daftar masalah dan analisis)
P: Planning (non Farmokologi dan Farmakologi)