FORMAT PEMERIKSAAN FISIK

STIKes MITRA HUSADA MEDAN

I. Biodata
Identitas Pasien
Nama : ...........................................................
Jenis kelamin : ...........................................................
Umur : ...........................................................
Status perkawinan : ............................................................
Agama : ...........................................................
Pendidikan : ...........................................................
Pekerjaan : ...........................................................
Alamat : ...........................................................
II. Keluhan utama
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
III. Riwayat Kesehatan Sekarang
1. Provocative / palliative
a.Apa Penyebabnya
...................................................................................................................................................................
...................................................................................................................................................................
b. Hal-hal yang memperbaiki keadaan
.................................................................................................................................................................
.................................................................................................................................................................
2. Quantity / Quality
a.Bagaimana dirasakan
.................................................................................................................................................................
.................................................................................................................................................................
b.Bagaiman dilihat
.................................................................................................................................................................
.................................................................................................................................................................
3. Region
a.Dimana lokasinya
.................................................................................................................................................................
.................................................................................................................................................................
b.Apakah menyebar
.................................................................................................................................................................
.................................................................................................................................................................
4. Severity ( Menggangu aktifitas )
.................................................................................................................................................................
.................................................................................................................................................................
5. Time (Kapan mulai timbul dan bagaiman terjadinya )
.................................................................................................................................................................
 .................................................................................................................................................................
IV. Riwayat Kesehatan Masa Lalu
1.Penyakit yang pernah dialami
.................................................................................................................................................................
2.Pengobatan / tindakan yang dilakukan
.................................................................................................................................................................
.................................................................................................................................................................
3.Pernah dirawat / dioperasi
.................................................................................................................................................................
.................................................................................................................................................................
4.Lamanya dirawat
.................................................................................................................................................................
.................................................................................................................................................................
5.Alergi
.................................................................................................................................................................
.................................................................................................................................................................
6.Imunisasi
.................................................................................................................................................................
.................................................................................................................................................................
V. Riwayat Kesehatan Keluarga
1.Orang tua
.................................................................................................................................................................
.................................................................................................................................................................
2.Saudara kandung
.................................................................................................................................................................
.................................................................................................................................................................
3.Penyakit keturunan yang ada
.................................................................................................................................................................
.................................................................................................................................................................
4.Anggota keluarga yang meninggal
.................................................................................................................................................................
.................................................................................................................................................................
5.Penyebab meninggal
.................................................................................................................................................................
VI. Riwayat / keadaan psikososial
1.Bahasa yang digunakan
.................................................................................................................................................................
.................................................................................................................................................................
2.Persepsi pasien tentang penyakitnya
.................................................................................................................................................................
.................................................................................................................................................................
3.Konsep diri
a.Body image : ..................................................................................................................
b.Ideal diri : .................................................................................................................
c.Harga diri : .................................................................................................................
d.Peran diri : .................................................................................................................
 e.Personal identity : .................................................................................................................
4.Keadaan emosi
.................................................................................................................................................................
.................................................................................................................................................................
5.Perhatian terhadap orang lain/lawan bicara
.................................................................................................................................................................
.................................................................................................................................................................

6.Hubungan dengan keluarga

.................................................................................................................................................................
.................................................................................................................................................................
7.Hubungan dengan saudara
.................................................................................................................................................................
.................................................................................................................................................................
8.Hubungan dengan orang lain
.................................................................................................................................................................
.................................................................................................................................................................
9.Kegemaran
.................................................................................................................................................................
.................................................................................................................................................................
10.Daya adaptasi
.................................................................................................................................................................
.................................................................................................................................................................
11. Mekanisme pertahanan diri
.................................................................................................................................................................
.................................................................................................................................................................
VII. Pemeriksaan Fisik
1.Keadaan umum
.................................................................................................................................................................
.................................................................................................................................................................
2.Tanda-tanda vital
Suhu tubuh : ………… 0C Nadi : …………… x/i
TD : ……….... mmHg RR : …………… x/i
TB : ………… cm BB : …………… kg
3.Pemeriksa kepala dan leher
a.Kepala dan rambut
-Kepala
• Bentuk : .....................................................................................................
• Ubun –ubun : ....................................................................................................
• Kulit kepala : .....................................................................................................
-Rambut
• Penyebaran dan keadaan rambut : ..........................................................................
• Bau : ..........................................................................
• Warna kulit : .........................................................................
-Wajah
• Warna kulit : ....................................................................................................
 • Struktur : ....................................................................................................
b. Mata
• Kelengkapan dan kesemetrisan : ...........................................................................
• Palpebra : ..........................................................................
• Konjungtiva dan Sklera : ..........................................................................
• Pupil : ..........................................................................
• Kornea dan iris : ..........................................................................
• Visus : ............................................................................
• Tekanan bola mata : ..........................................................................

c.Hidung
-tulang hidung dan posisi septum nasi : ..........................................................................
-Lubang hidup : ..........................................................................
-Cuping hidung : ..........................................................................
d.Telinga
-Bentuk telinga : ...........................................................................
-Ukuran telinga : ..........................................................................
-Lubang telinga : ...........................................................................
-Ketajaman pendengaran : ..........................................................................
e.Mulut dan faring
-Keadaan dan faring : .............................................................................
-Keadaan gusi dan gigi : ..........................................................................
-Keadaan lidah : ...........................................................................
-Orofaring : ...........................................................................
f.Leher
-Posisi trachea : ...........................................................................
-Thyroid : ...........................................................................
-Suara : ...........................................................................
-Kelenjar limfe : ............................................................................
-Vena jugularis : ............................................................................
-Denyut nadi karotis : ...........................................................................

4.Pemeriksaan integument
a.Kebersihan : ...........................................................................
b.Kehangatan : ...........................................................................
c.Warna : ...........................................................................
d.Turgor : ...........................................................................
e.Kelembaban : ...........................................................................
f.Kelainan pada kulit : ...........................................................................

5.Pemeriksaan payudara dan ketiak

a.Ukuran dan bentuk payudara : ...........................................................................
b.Warna payudara dan aerola : ...........................................................................
c.Kelainan payudara dan putting : ...........................................................................
d.Aksila dan clavicula : ...........................................................................
6.Pemeriksaan thoraks/dada
a.Inspeksi thoraks
- Bentuk thoraks : ............................................................................
- Pernapasan
• Frekwensi : .........................................................................
• Irama : ...........................................................................
-Tanda kesulitan bernapas : ...........................................................................
b.Pemerksaan paru
-Palpasi getaran suara : ............................................................................
-Perkusi : ............................................................................
-Auskultasi
• Suara napas : ...........................................................................
• Suara ucapan Suara napas : ...........................................................................
c.Pemeriksaan jantung
a.Inspeksi : ..........................................................................
b.Palpasi : ..........................................................................
• Pulsasi : ..........................................................................
• Ictus cordis : ..........................................................................
c.Perkusi
• Batas jantung : ..........................................................................
d.Auskultasi
• Bunyi jantung I : ...........................................................
• Bunyi jantung II : ...........................................................
• Bunyi jantung tambahan : ...........................................................
• Murmur : ...........................................................
• Frekwensi : ...........................................................

7.Pemeriksaan abdomen
a.Inspeksi
• Bentuk abdomen ............................................................................................
• Benjolan/massa ..............................................................................................
• Bayangan pembuluh darah ............................................................................
b.Auskultasi
• Peristaltik usus ................................................................................................
c. Palpasi
• Tanda nyeri tekan ...........................................................................................
• Benjolan/massa ...............................................................................................
• Tanda ascites...................................................................................................
• Hepar...............................................................................................................
• Lien .................................................................................................................
• Titik Mc.Burney .............................................................................................
d.Perkusi
• Suara abdomen................................................................................................
• Pemeriksaan ascites ........................................................................................
8.Pemeriksaan kelamin dan daerah sekitarnya
a.Genitalia
• Rambut pubis ..................................................................................................
• Lubang uretra ..................................................................................................
• Kelainan pada genetalia eksternal dan daerah inguinal ..................................

b.Anus dan parineum

• Lubang anus....................................................................................................
• Kelainan pada anus .........................................................................................
• Perineum .........................................................................................................

9.Pemeriksaan muskulos keletal/ekstremitas

• Kesemitrisan otot ............................................................................................
• Pemeriksaan edema ........................................................................................
• Kekuatan otot..................................................................................................
• Kelainan pada ekstrimitas dan kuku ...............................................................

10.Pemeriksaan neurologi
a.Tingkat kesadaran
• GCS: ..............................................................................................................
• E: ....................................................................................................................
• M:....................................................................................................................
• V: ...................................................................................................................

b.Meningeal sign .................................................................................................................

c.Status mental
• Kondisi emosi/perasaan ..................................................................................
• Orientasi..........................................................................................................
• Proses berpikir (ingatan,atensi,keputusan,perhitungan) ................................
• Motivasi/kemauan...........................................................................................
• Bahasa .............................................................................................................
d.Nervus cranial
• Nervus olfaktorius /N I ...................................................................................
• Nervus optikus/N II ........................................................................................
• Nervus okulomotoris/N III,Troechlearis/N IV,Abdusen/N VI .......................
• Nervustrigeminus/N V ....................................................................................
• Nervus fasialis/N VII ......................................................................................
• Nervus vestibulocochlearis/N VIII .................................................................
• Nervus glossopharigeus/N IX,Vegus N X ......................................................
• Nervus Asesorius/N XI ...................................................................................
• Nervus hipogloses/N XII ................................................................................

e.Fungsi motorik
• Cara berjalan : .................................................................................
 • Romberg test : .................................................................................
• Tes jari hidung : ................................................................................
• Pronasi-supinasi test : .................................................................................
• Heel to shin test : ................................................................................
f.Fungsi sensoris
• Identifikasi sentuhan ringan : .........................................................................
• Test tajam tumpul : ........................................................................
• Test panas dingin : ........................................................................
• Test getaran : ........................................................................
• Streognosis test : .......................................................................
• Graphestensia teks : .......................................................................
• Membedakan dua titik : .......................................................................
• Topognosis teks : ......................................................................
g.Reflek
• Reflek bisep : .................................................................................
• Reflek trisep : .................................................................................
• Reflek brachioradialis : .................................................................................
• Reflek patelar : .................................................................................
• Reflek tendonachiles : .................................................................................
• Reflek plantar : ...............................................................................
11.Pola Kebiasaan Sehari-hari
1.Pola tidur dan kebiasaan
• Waktu tidur .....................................................................................................
• Waktu bangun .................................................................................................
• Masalah tidur .................................................................................................
• Hal-hal yang mempengaruhi tidur ..................................................................
• Hal-hal yang mempermudah bangun ..............................................................
2.Pola eliminasi
1.BAB
• Pola BAB: Penggunaan laksatif : Ya/Tidak
• Karakter feses: BAB terakhir
• Riwayat perdarahan : Diare : Ya/tidak
2.BAK
a.Pola BAK Inkontinensi :………………. Ya/Tidak
b.Karakter Urine Retensi :………………..Ya/Tidak
c.Nyeri/rasa terbakar/kesulitan BAK : Ya/Tidak
d.Riwayat penyakit ginjal/kandunug kemih : Ya/Tidak
e.Penggunaan diuretika : Ya/Tidak

3.Upaya mengatasi masalah

......................................................................................................................................................
......................................................................................................................................................
4.Pola Makan dan Minum
a.Gejala (Subjektif) : …………………………………………………………………
b.Diit (Type) : ……………………….. Jumlah makanan perhari …………….
 c.Kehilangan selera makan : Ya/ Tidak
d.Nyeri Ulu hati
e.Yang berhubugan dengan : ....................................................................................................
f.Disembuhkan dengan
g.Alergi/Intoleransi makanan: ...................................................................................................
h.Berat badan biasa
h.Tanda (Objektif)
Berat badan sekarang
5.Waktu pemberian Makanan
6.Jumlah dan jenis makanan
7.Waktu pemberiana cairan
8.Masalah makan dan minum
a.Kesulitan mengunyah
b.Kesulitan menelan
c.Tidak dapat makan sendiri
9.Upaya mengatasi masalah
10.Kebersihan Diri/Personal Hygiene
a.Pemeliharaan Badan
b.Pemeliharaan gigi dan Mulut
c.Pemeliharaan Kuku
11.Pola kegiatan /Aktivitas
VIII.Diagnosa Pasien
IX.Tindakan yang dilakukan
X.Pengobatan yang dilakukan
XI.Kesimpulan
Pemeriksa
Nama Mahasiswa
( )
Mual Muntah: Ya/ Tidak
: ....................................................................................................
: ....................................................................................................
: .....................................................................................................
: …….. Kg Tinggi badan …………. Cm,
Bentuk badan …………………………………
: ........................................................................................
: ........................................................................................
: ....................................................................................... :
: .........................................................................................
: ........................................................................................
: ........................................................................................
: ........................................................................................
: .......................................................................................
: .......................................................................................
: .......................................................................................
: .......................................................................................
..................................................................................................... :
......................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
....................................................................................................
....................................................................................................
....................................................................................................
Pasien
( )