KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

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 PASIEN

NAMA MAHASISWA :

STAMBUK :

PEMBIMBING :
DEPARTEMEN ILMU PENYAKIT DALAM
FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
MAKASSAR

CATATAN RIWAYAT PENYAKIT

NAMA PENDERITA : NO. REKAM MEDIK :

JENIS KELAMIN : RUMAH SAKIT :
TANGGAL LAHIR : STATUS PASIEN : R. Jalan / R.Inap
ALAMAT : DOKTER YANG MEMERIKSA :
TGL PEMERIKSAAN : NAMA MPPD :

I. ANAMNESIS TERPIMPIN

KELUHAN UTAMA:

RIWAYAT PENYAKIT SEKARANG:

RIWAYAT PENYAKIT DAHULU:

RIWAYAT KELUARGA:

II. PEMERIKSAAN FISIK

Status Present

Sakit Ringan / Sakit Sedang / Sakit Berat

Gizi Kurang / Cukup / Baik
Kesadaran: /GCS:
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 :

- Inspeksi :
- 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 :...................................................................................................

III. PEMERIKSAAN PENUNJANG:

IV. RESUME :
V. DAFTAR MASALAH DAN PENGKAJIAN
1. Masalah:
Diagnosis diferensial:
Pengkajian:

2. Masalah:
Diagnosis diferensial:
Pengkajian:

3. Masalah:
Diagnosis diferensial:
Pengkajian:

4. Masalah:
Diagnosis diferensial:
Pengkajian:
5. Masalah:
Diagnosis diferensial:
Pengkajian:

VI. PLANNING
Terapi:

Resep :
Rencana Pemeriksaan:

VII. PROGNOSIS
Ad Functionam :
Ad Sanationam :
Ad Vitam :
Makassar, .............................. 20...

Dibuat oleh, Diperiksa dan disetujui oleh,

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