BAGIAN/SM ILMU KESEHATAN ANAK & REMAJA

RSUD DR. DORIS SYLVIANUS PALANGKA RAYA

PROGRAM STUDI PENDIDIKAN DOKTER
UNIVERSITAS PALANGKA RAYA
STATUS DOKTER MUDA
KEPANITERAAN KLINIK
Nama Mahasiswa : NIM :
Tanggal : Paraf :

STATUS UMUM ANAK

I. IDENTITAS
1. Identitas Penderita :
- Nama Penderita : ..................................................................................................................................
- Jenis Kelamin : ..................................................................................................................................
- Tempat/tanggal lahir :…………………………………………………………………….Umur:……….........Tahun:…………….Bulan:………………
2. Identitas Orang Tua/Wali:
- Ayah : Nama : ...................................................................................................................................
Pendidikan : ..................................................................................................................................
Pekerjaan : ..................................................................................................................................
Alamat : ..................................................................................................................................
- Ibu : Nama : ..................................................................................................................................
Pendidikan : ..................................................................................................................................
Pekerjaan : ..................................................................................................................................
Alamat : ..................................................................................................................................

II. ANAMNESIS
Kiriman dari : ..................................................................................................................................
Dengan diagnosis : ..................................................................................................................................
Alloanamnesis dengan : ..................................................................................................................................
Tanggal/Jam : ..................................................................................................................................
1. Keluhan Utama : ..................................................................................................................................
2. Riwayat Penyakit Sekarang : ..................................................................................................................................
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3. Riwayat Penyakit Dahulu (beri tanda √ pada penyakit yang pernah dialami)
Campak Diare Sesak
Batuk rejan Kuning Eksim
TBC Cacing Urtikaria
Difteri Kejang Sakit tenggorokan
Tetanus Demam

4. Riwayat Kehamilan dan Persalinan

 Riwayat antenatal : ..................................................................................................................................
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 Riwayat natal : ..................................................................................................................................
 Spontan/tidak spontan : ..................................................................................................................................
 Nilai APGAR : ..................................................................................................................................
 Berat badan lahir : ..................................................................................................................................
 Panjang badan lahir : ..................................................................................................................................
 Lingkar kepala : ..................................................................................................................................
 Penolong : ..................................................................................................................................
 Tempat : ..................................................................................................................................
 Riwayat neonatal : ..................................................................................................................................

5. Riwayat Perkembangan
 Tiarap :…………………………………………………………………………………………..bulan/tahun
 Merangkak :…………………………………………………………………………………………..bulan/tahun
 Duduk :…………………………………………………………………………………………..bulan/tahun
 Berdiri :…………………………………………………………………………………………..bulan/tahun
 Berjalan :…………………………………………………………………………………………..bulan/tahun
 Saat ini :…………………………………………………………………………………………..bulan/tahun

6. Riwayat Imunisasi (tulis umur)

Dasar Ulangan
Jenis (Umur dalam bulan
(Umur dalam hari/bulan)
BCG
Polio
Hepatitis B
DPT
Campak
7. Makanan (tulis jenis, kualitas, kuantitas, dan umur)

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8. Riwayat Keluarga
Ikhtisar keturunan: (Gambar skema keluarga dan beri tanda keluarga yang menderita penyakit sejenis)

Susunan Keluarga
Jelaskan:
No. Nama Umur L/P Sehat/ Sakit (apa)/
Meninggal (umur/sebab)

9. Riwayat Sosial Lingkungan

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III. PEMERIKSAAN FISIK
1. Keadaan Umum : ..............................................................................................................................................
Kesadaran : kompos mentis/apatis/somnolen/stupor/koma
GCS : ..............................................................................................................................................

2. Pengukuran
Tanda vital : Tensi :……………………………………………….…..mmHg
Nadi :…………………………………………….……..x/menit, kualitas: ..............................................
Suhu :…………………………………………………….℃
Respirasi :…………………………………………………….x/menit
Berat badan :…………………………………………………….kg (…………………………% standar BB/U)
Panjang/tinggi badan :……………………………………………………cm (…………………………% standar PB-TB/U)
…………………………………………………… (…………………………% standar BB/TB)
Lingkar lengan atas : ………………………………………………….cm (untuk 5 tahun ke atas)
Lingkar kepala :…………………………………………………..cm

3. Kulit
Warna : ..................................................................................................................................
Sianesis : ..................................................................................................................................
Hermangiom : ..................................................................................................................................
Turgor : ..................................................................................................................................
Kelembaban : ..................................................................................................................................
Pucat : ..................................................................................................................................
Lain-lain : ..................................................................................................................................

4. Kepala
Bentuk : ..................................................................................................................................
UUB : ..................................................................................................................................
UUK : ..................................................................................................................................
Lain-lain : ..................................................................................................................................

Rambut: Warna : ..................................................................................................................................

Tebal/tipis : ..................................................................................................................................
Distribusi : jarang/tidak ..............................................................................................................
Alopesia : ..................................................................................................................................
Lain-lain : ..................................................................................................................................

Mata: Palpebra : ..........................................................................................................

Alis, bulumata : ..........................................................................................................
Konjungtiva : ..........................................................................................................
Sklera : ..........................................................................................................
Produksi air mata : ..........................................................................................................
Pupil : Diameter : ..........................................................................................................
Simetris : ..........................................................................................................
 Refleks Cahaya : ..........................................................................................................
Kornea : ..........................................................................................................
Telinga: Bentuk : ..................................................................................................................................
Sekret : ..................................................................................................................................
Serumen : ..................................................................................................................................
Nyeri :………………………………………………………….. Lokasi : .......................................................
Hidung: Bentuk : ..................................................................................................................................
Pernapasan cuping hidung : ..............................................................................................................
Epistaksis : ..................................................................................................................................
Sekret : ..................................................................................................................................
Lain-lain : ..................................................................................................................................
Mulut: Bentuk : ..................................................................................................................................
Bibir : ..................................................................................................................................
Gusi : - mudah berdarah/tidak
- pembengkakan
Gigi geligi : ..................................................................................................................................
Lidah: Bentuk : ..................................................................................................................................
Pucat/tidak : ..................................................................................................................................
Tremor/tidak : ..................................................................................................................................
Kotor/tidak : ..................................................................................................................................
Warna : ..................................................................................................................................
Faring: Hiperemi : ..................................................................................................................................
Edema : ..................................................................................................................................
Membran/Pseudomembran : ...........................................................................................................

5. Leher
Vena jugularis: Pulsasi : ..................................................................................................................................
Tekanan : ..................................................................................................................................
Pembesaran kelenjar leher : ..................................................................................................................................
Kaku kuduk : ..................................................................................................................................
Massa : ..................................................................................................................................
Tortikolis : ..................................................................................................................................
6. Thoraks

 Dinding dada/paru
Inspeksi: Bentuk : ..................................................................................................................................
Retraksi : ..................................................................................................................................
Dispnea : ..................................................................................................................................
Pernapasan : ..................................................................................................................................
Palpasi: Fremitus fokal : ..................................................................................................................................
Perkusi : ..................................................................................................................................
Auskultasi: Suara napas dasar : ..........................................................................................................................
Suara napas tambahan : ...................................................................................................................

 Jantung
Inspeksi: Ictus cordis : ..................................................................................................................................
Palpasi: Apeks :………………………………………………………….. Lokasi : ......................................................
Thrill : ..................................................................................................................................
Perkusi: Batas kanan : ..................................................................................................................................
Batas kiri : ..................................................................................................................................
Batas atas : ..................................................................................................................................
Auskultasi: Frekuensi :………………………………………………x/menit, Irama: .......................................................
Suara dasar : ..................................................................................................................................
Bising :…………………………………………….. Derajat : ..................................................................
Lokasi: ....................................................................
Punctum max : ........................................................
Penyebaran: ............................................................

7. Abdomen
Inspeksi: Bentuk : ..................................................................................................................................
Lain-lain : ..................................................................................................................................
Palpasi: Hati : ..................................................................................................................................
Lien : ..................................................................................................................................
Ginjal : ..................................................................................................................................
Massa : ..................................................................................................................................
Ukuran : ......................................................................................................................
Lokasi : ......................................................................................................................
Permukaan : ......................................................................................................................
Konsistensi : ......................................................................................................................
Nyeri : ......................................................................................................................
Perkusi: Timpani/pekak: .................................................................................................................................
Asites : .................................................................................................................................
Auskultasi: .............................................................................................................................................................
 8. Ektremitas
Umum : ..........................................................................................................................................................
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Neurologis
Lengan Tungkai
Kanan Kiri Kanan Kiri
Gerakan
Tonis
Trofi
Klonus
Refleks Fisiologis
Refleks patologis
Sensibilitas
Tanda meningeal

9. Susunan Saraf : ..............................................................................................................................................

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10. Genitalia : ...............................................................................................................................................

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11. Anus : ...............................................................................................................................................

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IV. PEMERIKSAAN LABORATORIUM SEDERHANA

Darah : .......................................................................................................................................................................
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Urin : ......................................................................................................................................................................
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Feses : ......................................................................................................................................................................
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V. RESUME
Nama : ..............................................................................................................................................
Jenis Kelamin : ..............................................................................................................................................
Umur : ..............................................................................................................................................
Berat badan : ..............................................................................................................................................
Keluhan utama : ..............................................................................................................................................
Uraian : ..............................................................................................................................................
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Pemeriksaan Fisik
Keadaan umum : ..............................................................................................................................................
Kesadaran : ..............................................................................................................................................
Tensi : ..............................................................................................................................................
Denyut nadi : ..............................................................................................................................................
Pernapasan : ..............................................................................................................................................
Suhu : ..............................................................................................................................................
Kulit : ..............................................................................................................................................
Kepala : ..............................................................................................................................................
Mata : ..............................................................................................................................................
Telinga : ..............................................................................................................................................
Mulut : ..............................................................................................................................................
Thoraks/paru : ..............................................................................................................................................
Jantung : ..............................................................................................................................................
Abdomen : ..............................................................................................................................................
Ekstremitas : ..............................................................................................................................................
Susunan saraf : ..............................................................................................................................................
Genitalia : ..............................................................................................................................................
Anus : ..............................................................................................................................................

VI. DIAGNOSA
Diagnosa banding : ..............................................................................................................................................
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Diagnosa kerja : ..............................................................................................................................................
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 Status gizi : ..............................................................................................................................................
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VII. PENATALAKSANA
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VIII. USULAN PEMERIKSAAN
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IX. DIAGNOSIS
Quo ad vitam : ..............................................................................................................................................
Quo ad functionam : ..............................................................................................................................................
Quo ad sanationam : ..............................................................................................................................................
X. PENCEGAHAN
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