DEPARTEMEN

RUMAH SAKIT
ILMU PENYAKIT DALAM
dr. DORIS SYLVANUS
FAKULTAS KEDOKTERAN STATUS PASIEN
UNIVERSITAS PALANGKA RAYA Untuk Dokter Muda
Nama Dokter Muda Tanda Tangan
NIM
Tanggal
Rumah sakit RSUD dr. Doris Sylvanus
Gelombang Periode

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

II. ANAMNESIS
Keluhan Utama :
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Riwayat Penyakit Sekarang :
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Riwayat Penyakit Terdahulu :

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Riwayat Kebiasaan, Sosial Ekonomi dan Budaya :
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Riwayat Penyakit Keluarga :
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III. PEMERIKSAAN FISIK
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Keadaan Umum:........................................................................... GCS : E....V.... M....
Kesadaran : ..................................................................................................................................
BB:...... Kg TB:...... cm; IMT:......

Vital Sign
Tekanan Darah :.................................................................................................................
Pernapasan :.................................................................................................................
Nadi :.................................................................................................................
Suhu :.................................................................................................................
SpO2 :.................................................................................................................

Kepala
Bentuk :.............................................................................................................
Ukuran :.............................................................................................................
Rambut :.............................................................................................................
Mata :.............................................................................................................
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Telinga :.............................................................................................................
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Hidung : ............................................................................................................
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Mulut :............................................................................................................
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Leher
Kelenjar GB :............................................................................................................
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Tiroid :.............................................................................................................
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JVP :.............................................................................................................

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Thorax Anterior

Paru-paru
Inspeksi :......................................................................................................................
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Palpasi :......................................................................................................................
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Perkusi :......................................................................................................................
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Auskultasi : .....................................................................................................................
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Posterior
Paru-paru
Inspeksi :......................................................................................................................
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Palpasi :......................................................................................................................
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 Perkusi :......................................................................................................................
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Auskultasi :......................................................................................................................
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Jantung
Inspeksi : .....................................................................................................................
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Palpasi :......................................................................................................................
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Perkusi
Batas kanan :......................................................................................................................
Batas kiri :......................................................................................................................
Auskultasi : .....................................................................................................................
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Abdomen
Inspeksi :......................................................................................................................
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Auskultasi :......................................................................................................................
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 Perkusi :......................................................................................................................
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Palpasi :......................................................................................................................
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Anggota Gerak
Tangan :......................................................................................................................
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Motorik : Fungsi sensorik :

Kaki :......................................................................................................................
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Motorik : Fungsi sensorik :

IV. MASALAH
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V. KRITERIA DIAGNOSIS
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VI. ASSESMENT
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VI. DIAGNOSIS BANDING

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VII. PLANNING
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VIII. TERAPI
Non-Farmakologi
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Farmakologi
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IX. MONITORING
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X. EDUKASI
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XI. PROGNOSIS
- Ad vitam :...................................................................................................
- Ad Functional : ..................................................................................................
- Ad Sanationam : ..................................................................................................

Palangka Raya,
Mengetahui, DPJP Dokter Muda

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