IDENTITAS PASIEN
Nama : _________________ Jenis Kelamin : ___________________
Umur : _________________ Bangsa : ___________________
Pekerjaan : _________________ Agama : ___________________
Alamat : _________________ No. MR : ___________________
I. ANAMESIS
Diambil dari : __________________ Tanggal : ________________Jam : _______
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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A. STATUS UMUM
Keadaan Umum : ________________________________
Kesadaran : ________________________________
Keadaan gizi : ________________________________
Kulit : ________________________________
B. PEMERIKSAAN FISIK
• TANDA VITAL
Tekanan Darah : ___________ mmHg Nadi : _____________X/ menit
• LEHER
o Kelenjar Getah bening :
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o Kelenjar Gondok :
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o JVP :
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• DADA ( Thorax )
o Inpeksi :
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o Palpasi :
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o Perkusi :
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o Auskultasi :
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• PERUT ( ABDOMEN )
o Inpeksi :
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o Palpasi :
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o Perkusi :
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o Auskultasi :
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• REGIO LUMBAL ( FLANK AREA )
o Inpeksi :
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o Palpasi :
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o Perkusi :
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o Auskultasi :
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• EKSTREMITAS
o Superior :
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o Inferior :
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• GENITALIA
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• PERIANAL
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• NEUROMUSKULAR
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o Sensibilitas :
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o Refleks fisiologis :
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o Refleks Patologis :
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• TULANG BELAKANG
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C. STATUS LOKALIS
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B. Urine Rutin
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C. Faces Rutin
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IV. RESUME
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V. DIAGNOSIS BANDING
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B. LABORATORIUM KHUSUS
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X. PROGNOSIS
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