Mata Ujian: ILMU KESEHATAN ANAK

Tanggal Ujian: __________________________

Nama Mahasiswa : _____________________________ Tanda Tangan : ________

NPM : _____________________________

IDENTITAS
PASIEN
Nama Lengkap : ______________________ Suku Bangsa : ____________________
TTL (Umur) : ______________________ Agama : ____________________
Jenis Kelamin : ______________________ Pendidikan : ____________________
Alamat : ______________________

ORANG TUA/WALI
Ayah
Nama Lengkap : ______________________ Agama : ____________________
TTL (Umur) : ______________________ Pekerjaan : ____________________
Suku Bangsa : ______________________ Pendidikan : ____________________
Alamat : ______________________ Penghasilan : ____________________

Ibu
Nama Lengkap : ______________________ Agama : ____________________
TTL (Umur) : ______________________ Pekerjaan : ____________________
Suku Bangsa : ______________________ Pendidikan : ____________________
Alamat : ______________________ Penghasilan : ____________________

Wali
Nama Lengkap : ______________________ Agama : ____________________
TTL (Umur) : ______________________ Pekerjaan : ____________________
Suku Bangsa : ______________________ Pendidikan : ____________________
Alamat : ______________________ Penghasilan : ____________________

Hubungan dengan orang tua : anak kandung / angkat / tiri

*) Coret yang tidak perlu
RIWAYAT PENYAKIT

Keluhan Utama
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Keluhan Tambahan
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Riwayat Penyakit Sekarang (diisi secara lengkap, rinci, kronologis, dan jelas)
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RIWAYAT MAKANAN

Umur (Bulan) ASI / PASI Buah / Biskuit Bubur Susu Nasi Tim
0–2
2–4
4–6
6–8
8 – 10
10 – 12

Umur lebih dari 1 tahun

Jenis Makanan Frekuensi dan Jumlah
Nasi / Pengganti
Sayur
Daging
Telur
Ikan
Tahu
Tempe
Susu (merk / takaran)
Lain - lain
RIWAYAT PENYAKIT YANG PERNAH DIDERITA

Penyakit Umur
Diare
Otitis
Radang Paru
Tuberkulosis
Kejang
Ginjal
Jantung
Darah
Difteri
Morbili
Parotitis
Demam Berdarah
Demam Tifoid
Cacingan
Alergi
Kecelakaan
Operasi
Lain - lain
RIWAYAT KEHAMILAN DAN KELAHIRAN

Kehamilan
Perawatan
Antenatal

Penyulit
Kehamilan

Kelahiran
Perawatan Rumah sakit / Rumah bersalin / Rumah
Antenatal Lain – lain

Perawatan Dokter / Bidan / Dukun terlatih / Tradisional

Persalinan Lain - lain

Cara Spontan / Tindakan :

Persalinan Penyulit persalinan :

Masa Gestasi

Keadaan Berat badan lahir :

Bayi Panjang badan lahir :
Lingkar kepala :
Langsung / Tidak langsung menangis
Pucat / Biru / Kuning / Kejang
Nilai APGAR :
Kelainan bawaan :

RIWAYAT PERKEMBANGAN

Pertumbuhan gigi pertama : ______________________bulan

Psikomotor
Tengkurap : ______________________bulan
Duduk : ______________________bulan
Berdiri : ______________________bulan
Berjalan : ______________________bulan
Berbicara : ______________________bulan
Membaca & menulis: : ______________________bulan
PERKEMBANGAN PUBERTAS
Perempuan
Rambut pubis : ______________________bulan
Payudara : ______________________bulan
Menarche : ______________________bulan
Laki-laki
Rambut pubis : ______________________bulan
Perubahan suara : ______________________bulan

Gangguan perkembangan : ______________________ (jelaskan bila ada)

Mental / emosi

RIWAYAT IMUNISASI

Vaksin Dasar (Umur) Ulangan (Umur)

BCG
DPT/PT
Polio
Campak
Hepatitis B
MMR
TIPA
RIWAYAT KELUARGA

Corak Reproduksi

Tanggal
Jenis Lahir Mati Keterangan
No Lahir Hidup Abortus
Kelamin Mati (Sebab) Kesehatan
(Umur)

Data Keluarga
Ayah / Wali Ibu / Wali
Perkawinan ke
Umur saat menikah
Konsanguinitas
Keadaan kesehatan / Pernyakit bila ada

Riwayat Penyakit dalam Keluarga

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Riwayat Penyakit pada Anggota Keluarga lain / orang lain serumah :

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Data Perumahan
Kepemilikan rumah :
Keadaan rumah :
Keadaan lingkungan :
PEMERIKSAAN FISIK
Tanggal _____________________________ Pukul _____________________

PEMERIKSAAN UMUM
Keadaan Umum : _____________________________
Kesadaran : _____________________________

TANDA VITAL
Frekensi Nadi : _____________________________ x / menit
Tekanan Darah :_____________________________mmHg
Frekuensi Nafas :_____________________________x / menit
Suhu Tubuh :_____________________________ C (per Axilla)

DATA ANTROPOMETRI
Berat badan :_____________________________ kg
Tinggi badan :_____________________________cm
Lingkar kepala :_____________________________cm
Lingkar dada :_____________________________cm
Lingkar perut :_____________________________cm
Lingkar lengan atas :_____________________________cm
STATUS GIZI

WFA :

HFA :

WFH :

NCHS

BB / U :

TB / U :
PEMERIKSAAN SISTEMATIS
Kepala
Bentuk dan Ukuran :
Rambut dan kulit kepala :
Mata :
Telinga :
Hidung :
Bibir :
Gigi geligi :
Mulut :
Lidah :
Tonsil :
Faring :

Leher :

Thorax :
Dinding thorax :

Paru :

Jantung :

Abdomen :
Anus dan Ractum :

Genitalia :

Anggota gerak :

Tulang belakang :

Kulit :

Rambut :

Kelenjar getah bening :

Pemeriksaan neurologis :
PEMERIKSAAN LABORATORIUM

Darah Tepi :

Air seni / urin :

Tinja / Feses :

Lain – lain :
RINGKASAN
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DIAGNOSIS KERJA
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DIAGNOSIS BANDING
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ANJURAN PEMERIKSAAN PENUNJANG

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PROGNOSIS
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PENATALAKSANAAN
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TINDAK LANJUT
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