STATUS PASIEN

1. Identitas
Nama :_________________________________________
Tgl. Lahir/Umur :_________________________________________
Jenis Kelamin :_________________________________________
Alamat :_________________________________________
Tgl. Masuk RS :_________________________________________
Identitas Orang Tua
Ayah Ibu
Nama
Umur
Pendidikan terakhir
Pekerjaan

2. Anamnesis
a. Keluhan Utama :_________________________________________

b. Riwayat Penyakit Sekarang:

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c. Riwayat Penyakit Dahulu:
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d. Riwayat Penyakit Keluarga:
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e. Genogram:
f. Riwayat Kehamilan dan Persalinan:
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g. Riwayat Makan:
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h. Riwayat Imunisasi:
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 i. Riwayat Tumbuh-Kembang:
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j. Riwayat sosioekonomi dan Lingkungan:
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3. Anamnesis Sistem
a. SSP :_________________________________________
b. Kardiovaskuler :_________________________________________
c. Respirasi :_________________________________________
d. Gastrointestinal :_________________________________________
e. Genitourinaria :_________________________________________
f. Muskuloskeletal :_________________________________________
g. Integumen :_________________________________________
h. Termoregulasi :_________________________________________
4. Pemeriksaan Fisik
Kesan umum : _________________________________________

Antopometri

BB : BB/U:
TB/PB : TB/U:
LLA :
LK :

Tanda-tanda Vital
a. Nadi :_______________________________________________
b. Suhu :_______________________________________________
c. TD :_______________________________________________
d. Respirasi :_______________________________________________

Status generalisata

a. Kepala : normocephal
b. Mata : Konjungtiva anemis (__), sklera ikterik (__),
c. Telinga : Simetris, sekret (_/_), nyeri tekan (_/_)
d. Hidung : deviasi septum (__), nyeri tekan (__), sekret (__).
e. Tenggorokan : tonsil (T_/T_), hiperemis (__), dedritus (__)
f. Leher : Pembesaran KGB (__), Nyeri Tekan (__), JVP (__)
g. Paru :
Inpeksi : simetris (_), retraksi (_)
Palpasi :fremitus taktil kanan (___) kiri
Perkusi : sonor (__)________________________________
Auskultasi : SND vesikuler, Ronki (__/__), Wheezing (__/__)
h. Jantung :
Inspeksi : ictus codis tidak terlihat
Palpasi : IC teraba di SIC V linea midklavikula sinistra
Perkusi : batas jantung normal
Auskultasi : S1 tunggal, S2 split tak konstan, reguler, gallop
(__), murmur (__)
i. Abdomen :
Inspeksi : Distensi (__), keras seperti papan (__)
Auskultasi : Bising usus (__) normal
Perkusi : _________________________________________
Palpasi : hepar (_) dan lien (_)________________________
j. Ekstremitas : sianosis (_), edema (_), akral dingin (_),
CRT___2”,
5. Pemeriksaan Penunjang
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6. Diagnosis:
Fungsional :_______________________________________________
Etiologi :_______________________________________________
Anatomi :_______________________________________________
Lain-lain :_______________________________________________
7. Diagnosis Banding:
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8. Tatalaksana:
Medikamentosa Nonmedikamentosa