KEMENTERIAN RISET TEKNOLOGI & PENDIDIKAN TINGGI

UNIVERSITAS HASANUDDIN FAKULTAS KEDOKTERAN

DEPARTEMEN ILMU PENYAKIT DALAM/SMF PENYAKIT DALAM
RSUP Dr. WAHIDIN SUDIROHUSODO MAKASSAR
RSP UNHAS Gedung A Lt. 5 Jl. Perintis Kemerdekaan Km 11 Tlp/Fax. (0411) 586533 Tamalanrea - Makassar 90245, Email :
intern.fk.unhas@gmail.com Website : med.unhas.ac.id/interna

STATUS PENDERITA

DIAGNOSIS :

NAMA MAHASISWA :

STAMBUK :

PEMBIMBING :
DEPARTEMEN ILMU PENYAKIT DALAM
FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
MAKASSAR

CATATAN RIWAYAT PENYAKIT

NAMA PENDERITA : NO. REKAM MEDIK :

JENIS KELAMIN : TANGGAL PEMERIKSAAN :
TANGGAL LAHIR : DOKTER YANG MEMERIKSA :
ALAMAT : DOKTER MUDA :

I. SUBJEKTIF

KELUHAN UTAMA :

ANAMNESI TERPIMPIN :

II. OBJEKTIF
Status Present

Sakit Ringan/ Sakit Sedang/ Sakit Berat

Gizi Kurang/ Cukup/ Baik
Kesadaran Komposmentis / Inkomposmentis

BB: TB: IMT:

Tanda Vital :
Tensi :.............................mmHg
Nadi :.............................kali/menit
Pernapasan : ............................kali/menit Tipe :...........................................
Suhu :.............................oC

Kepala : Ekspresi :....................................... Deformitas :...............................

Simetris Muka :...................................... Rambut :...............................

Mata : Eksoftalmus/ Enoptalmus :.................... Gerakan :...............................

Tekanan Bola Mata :....................
Kelopak Mata :....................
Konjungtiva : Anemi + / - Kornea :...............................
Sklera : Ikterus + / - Pupil :...............................

Telinga : Tophi + / -
Nyeri Tekan di prosesus Mastoideus + / -

Hidung : Pendarahan + / - Sekret : + / -

Mulut : Bibir :..................................... Tonsil :..........................................

Gigi Geligi :..................................... Farings :..........................................
Gusi :..................................... Lidah :..........................................

Leher : Kelenjar Getah Bening :..........................................................

 Kelenjar Gondok :..........................................................
DVS :..........................................................
Pembuluh Darah :..........................................................
Kaku Kuduk :..........................................................
Dada :
Inspeksi :..........................................................
Bentuk :..........................................................
Pembuluh Darah :..........................................................
Buah Dada :..........................................................
Sela Iga :..........................................................
Lain-lain :..........................................................

Paru :

- Palpasi Fremitus Raba :...............................................

Nyeri Tekan :...............................................

- Perkusi Paru Kiri :...............................................

Paru Kanan :...............................................
Batas Paru-Paru :...............................................
Batas Paru Belakang Kanan :...............................................
Batas Paru Belakang Kiri :...............................................
- Auskultasi :

Jantung :
 - Inspeksi :...............................................
- Palpasi :...............................................
- Perkusi :...............................................
- Auskultasi : BJ I/ II :...............................................
Bunyi Tambahan :...............................................

Perut :
- Inspeksi :

- Palpasi :...........................................................................................
Hati :..........................................................................................
Limpa :..........................................................................................
Ginjal :..........................................................................................
Lain-lain :..........................................................................................
- Perkusi :..........................................................................................
- Auskultasi :..........................................................................................

Alat Kelamin :..........................................................................................

Anus dan Rektum :..........................................................................................

Punggung :..........................................................................................
- Palpasi :..........................................................................................
- Nyeri Ketok :..........................................................................................
- Auskultasi :..........................................................................................
- Gerakan :..........................................................................................
- Lain-lain :..........................................................................................

Ekstremitas :...................................................................................................
Laboratorium :
Pemeriksaan Penunjang Lain :

RESUME :

III. ASSESSMENT
IV. PLANNING
Pengobatan:

Rencana Pemeriksaan:

V. PROGNOSIS
Ad Functionam :
Ad Sanationam :
Ad Vitam :