RUMAH SAKIT DORIS

SYLVANUS/ DEPARTEMEN ILMU PENYAKIT DALAM

UNIVERSITAS
PALANGKARAYA STATUS PASIEN
FAKULTAS
Untuk Dokter Muda
KEDOKTERAN
Nama Dokter Muda DWINDO KUSUMO, S.Ked Tanda Tangan
NIM FAB 118 047
Tanggal
Rumah sakit RSUD DR. DORIS SYLVANUS
Gelombang Periode

I. IDENTITAS
Nama : ...................................................................................................................
Umur : ...................................................................................................................
Jenis Kelamin : ...................................................................................................................
Agama : ...................................................................................................................
Pendidikan Terakhir : ...................................................................................................................
Alamat : ...................................................................................................................
Tanggal Pemeriksaan : ...................................................................................................................
Ruangan : ...................................................................................................................
MRS : ....................................................................................................................

II. ANAMNESIS
Keluhan Utama: ................................................................................................................................

Riwayat Penyakit Sekarang: .............................................................................................................

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 Riwayat Penyakit Terdahulu:
 Asma : Ya / Disangkal
 Gastritis : Ya / Disangkal
 Stroke : Ya / Disangkal
 DM : Ya / Disangkal
 Hipertensi : Ya / Disangkal
 Penyakit lain : ..........................................................................................................................
 Faktor resiko : ..........................................................................................................................

Riwayat Penyakit Keluarga: ..............................................................................................................

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Riwayat pengobatan : ……………………………………………………………………………………………………………………

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Riwayat social/lingkungan : ……………………………………………………………………………………………………………..

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III. PEMERIKSAAN FISIS
Keadaan Umum : ...............................................................................................................................
Status Present : ........ / ........ / ........
BB: ………. Kg TB: ………. Cm IMT: ………. Kg/m2

 Vital Sign
Tekanan Darah : ………………. mmHg Suhu : ………. ℃
Pernapasan : ………. Kali/Menit Nadi : ………. Kali/Menit

 Kepala
Mata: a) Konjungtiva: anemis (…../…..) b) Sklera: ikterik (…../…..)
Lain- lain :
Hidung a) sektret (..…/……) B. Epistaksis (…./…..)
Bibir a). kering (…..) b. sianosis (…..) c. pucat (…..)
Faring hiperemis (…..) perbesaran tonsil ( T.…/T….)
Gusi berdarah (….)
Lain lain :

 Leher
Kelenjar GB : .................................................................................................................................
Tiroid : .................................................................................................................................
JVP : .................................................................................................................................
Massa lain : .................................................................................................................................

 Dada
a) Paru-Paru
ANTERIOR
◦ Inspeksi : .............................................................................................................................
◦ Palpasi : .............................................................................................................................
◦ Perkusi : .............................................................................................................................
◦ Auskultasi : .............................................................................................................................
POSTERIOR
◦ Inspeksi : .............................................................................................................................
◦ Palpasi : .............................................................................................................................
 ◦ Perkusi : .............................................................................................................................
◦ Auskultasi : .............................................................................................................................

b) Jantung
◦ Inspeksi : .............................................................................................................................
◦ Palpasi : .............................................................................................................................
◦ Perkusi :
- Batas jantung kanan :
- Batas jantung kiri :

◦ Auskultasi : .............................................................................................................................

 Perut
◦ Inspeksi : .................................................................................................................................
◦ Auskultasi : .................................................................................................................................
◦ Palpasi : .................................................................................................................................
◦ Perkusi : .................................................................................................................................
Pemeriksaan lain –lain :

 Anggota Gerak
◦ Atas : .................................................................................................................................
◦ Bawah : .................................................................................................................................

Pemeriksaan Khusus: ............................................................................................................................

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IV. DAFTAR MASALAH
Anamesis Pemeriksaan Fisik
1. 1.
2. 2.
3. 3

V. ASSESMENT
1.
2.

VI. DIAGNOSIS BANDING

1.
2.
3.
4.
5.

VII. PLANNING
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VIII. TERAPI
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IX. MONITORING
1. .................................................................
2. ……………………………………………………………..
3. ………………………………………………………………….
X. EDUKASI
1.
2.
3.
4.

XI. PROGNOSIS

Palangka Raya, 2019

Dokter Muda

(DWINDO KUSUMO, S.Ked)

NIM. FAB 118 047