Status Ujian Ilmu Bedah

Menara YARSI, Kav. 13 Lt. 1, Jl. Letjend Suprapto No.1, RT.10/RW.5, Cemp.
Putih Tim., Kec. Cemp. Putih, Kota Jakarta Pusat, Daerah Khusus Ibukota
Jakarta 10510.

KEPANITERAAN KLINIK
STATUS ILMU BEDAH
FAKULTAS KEDOKTERAN UYARSI
Hari/Tanggal Ujian/Presentasi Kasus : …………………
SMF ILMU PENYAKIT BEDAH
RUMAH SAKIT: …………………
Nama :…………………………………. Tanda Tangan

NIM :………………………………… ………………………

Dr. Pembimbing/ Penguji :……………………….
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IDENTITAS PASIEN
Nama :…………………………….. Umur :……………………………..
Pekerjaan :…………………………….. Alamat :……………………………..
Jenis Kelamin :…………………………...... Bangsa :……………………………..
Agama :……………………………..

I. ANAMNESIS
Diambil dari: …………………………. Tanggal:……………….. Jam:………….
1. Keluhan Utama
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2. Keluhan Tambahan
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3. Riwayat Penyakit Sekarang

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4. Riwayat Penyakit Keluarga
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5. Riwayat Masa Lampau

a. Penyakit Terdahulu : ________________________________________________
b. Trauma Terdahulu : ________________________________________________
c. Operasi : ________________________________________________
d. Sistem Saraf : ________________________________________________
e. Sistem Kardiovaskular : ________________________________________________
f. Sistem Gastrointestinalis : ________________________________________________
g. Sistem Urinarius : ________________________________________________
h. Sistem Genitalis : ________________________________________________
i. Sistem Muskuloskeletal : ________________________________________________
II. STATUS PRAESENS
1. STATUS UMUM
Keadaan Umum : Dada :
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Kesadaran : Paru :
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Keadaan Gizi : Jantung :
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Pernapasan : Perut :
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Suhu :____oC Hati :
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Tekanan Darah :_____/_____mmHg
Limpa :
Nadi :
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Ginjal :
Kelenjar Limfe :
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Kandung Empedu :
Kepala :
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Kandung Kemih :
Kulit :
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Kemaluan :
Muka :
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Punggung :
Mata :
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Rektum/Anus :
Hidung :
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Ekstremitas :
Mulut/Gigi :
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Sensibilitas :
Leher :
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Motorik :
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2. STATUS LOKALIS
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III. PEMERIKSAAN KHUSUS LAIN
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IV. LABORATORIUM (Data sekunder, diberikan sebelum pemeriksaan kasus)
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V. RESUME
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VI. DIAGNOSIS KERJA

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VII. DIAGNOSIS BANDING
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VIII. PEMERIKSAAN ANJURAN
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IX. PENGOBATAN
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X. PROGNOSIS
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