BAGIAN ORTHOPEDI & TRAUMATOLOGI

FAKULTAS KEDOKTERAN
UNIVERSITAS MUSLIM INDONESIA

STATUS PENDERITA

DIAGNOSIS : ………………………………………………………….

NAMA MAHASISWA : ……………………………………………...

STAMBUK : ……………………………………………...
PEMBIMBING : ……………………………………………...
PENGUJI : ……………………………………………...
 STATUS UJIAN KASUS

1.1 IDENTITAS PASIEN

Nama :
Umur :
Jenis Kelamin :
Pekerjaan :
Agama :
Alamat :
Tanggal Masuk :
Tanggal Pemeriksaan :
No. RM :

1.2 ANAMNESIS
1. Keluhan Utama :

2. Riwayat Penyakit Sekarang :

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3. Riwayat Penyakit Dahulu
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4. Riwayat Pengobatan

5. Riwayat Operasi
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6. Riwayat Keluarga
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1.3 PEMERIKSAAN FISIK

A. PRIMARY SURVEY
 Airway and C-spine control
Airway :
C-Spine control :
 Breathing :
Inspeksi :

Palpasi :

Perkusi :
Auskultasi :
 Circulation :

 Disability :
 Environment :

Status generalis :

B. SECONDARY SURVEY
Status Lokalis :
• Look :
• Feel :
• Move :
• NVD :
 Right Left
TLL
ALL
LLD

1.4 PEMERIKSAAN PENUNJANG

1.5 RESUME
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1.6 DIAGNOSA KERJA

1.7 PENATALAKSANAAN
1. Non operatif

2. Operatif

1.8 PROGNOSIS
Ad Functionam :
Ad Sanationam :
Ad Vitam :