STATUS UJIAN KOAS BEDAH

RS PERTAMINA BINTANG AMIN BANDAR LAMPUNG

TANGGAL : _______________________________

RUANG : _______________________________

Nama Koas : ________________________________

NPM : ________________________________ Tanda Tangan : __________________

IDENTITAS PASIEN

Nama :_________________________ Jenis Kelamin :_________________________

Umur :_________________________ Bangsa :_________________________

Pekerjaan :_________________________ Agama :_________________________

Alamat :_________________________ No.MR :_________________________

I. ANAMNESA

Diambil dari : ___________________________

1. Keluhan Utama
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2. Keluhan Tambahan
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3. Riwayat Penyakit
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4. Riwayat Keluarga
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 5. Riwayat Masa Lampau
a. Penyakit Terdahulu :___________________________________________________
b. Trauma Terdahulu :___________________________________________________
c. Operasi :___________________________________________________
d. Sistem Saraf :___________________________________________________
e. Sistem Kardiovaskuler :___________________________________________________
f. Sistem Gastrointestinal :___________________________________________________
g. Sistem Urinarius :___________________________________________________
h. Sistem Genitalis :___________________________________________________
i. Sistem Muskuloskeletal :___________________________________________________

II. STATUS PRESENT

A. STATUS UMUM
Keadaan Umum:______________________________
Kesadaran :______________________________
Keadaan Gizi :______________________________
Kulit :______________________________

B. PEMERIKSAAN FISIK
 Tanda Vital
Tekanan Darah : _____________mmHg Nadi :____________x/menit
Pernafasan :_____________x/menit Suhu :____________C

 Kepala dan Muka

Bentuk dan ukuran :_________
Mata
Konjungtiva :__________________ Reflek cahaya :___________________
Sklera :__________________ Pupil :___________________
Telinga :___________________________________________________
Hidung :___________________________________________________
Tenggorokan :___________________________________________________
Mulut :___________________________________________________
Gigi :___________________________________________________

 Leher
Kel.Getah Bening :___________________________________________________
Kel.Gondok :___________________________________________________
JVP :___________________________________________________

 Dada (Thorax)
Inpeksi :___________________________________________________
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Palpasi :___________________________________________________
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Perkusi :___________________________________________________
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Auskultasi :___________________________________________________
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 Perut (Abdomen)
Inpeksi :___________________________________________________
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Palpasi :___________________________________________________
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Perkusi :___________________________________________________
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Auskultasi :___________________________________________________
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 Region Lumbal (Falank Area)

Inpeksi :___________________________________________________
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Palpasi :___________________________________________________
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Perkusi :___________________________________________________
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Auskultasi :___________________________________________________
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 Ekstremitas
Superior :___________________________________________________
Inferior :___________________________________________________

 Genitalia
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 Perianal
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 Neuromuscular
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- Sensibilitas : ___________________________________________________
- Reflek Fisiologis : ___________________________________________________
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- Reflek Patologis : ___________________________________________________
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 Tulang Belakang
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 C. STATUS LOKALIS
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III. LABORATORIUM RUTIN

A. Darah Rutin
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B. Urine Rutin
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C. Fases Rutin
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IV. RESUME

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V. DIAGNOSA BANDING

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VI. DIAGNOSA KERJA

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VII. PENATALAKSANAAN DAN PENGOBATAN

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VIII. PEMERIKSAAN PENUNJANG

A. RADIOLOGI
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B. LABORATORIUM KHUSUS
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IX. PEMERIKSAAN ANJURAN

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X. PROGNOSIS

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XI. TINJAUAN KEPUSTAKAAN (PADA CASE REPORT)

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