STATUS DOKTER MUDA

KEPANITERAAN KLINIK ILMU KEDOKTERAN KOMUNITAS

Nama Mahasiswa : ________________________

NPM : ________________________ Tanggal : _________

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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5. Riwayat penyakit dahulu

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A. STATUS UMUM
Keadaan Umum : ________________________________
Kesadaran : ________________________________
Keadaan gizi : ________________________________
Kulit : ________________________________

B. PEMERIKSAAN FISIK

 TANDA VITAL
Tekanan Darah : ___________ mmHg Nadi : _____________X/ menit
Pernafasan : ___________ X/ menit Suhu : _____________ 0 C

 KEPALA DAN WAJAH

o Bentuk dan Ukuran :
o Mata :
Konjungtiva : _______ Reflek Cahaya :_________________
Sklera : ______ Pupil :_________________
o Telinga : ______________________________________
o Hidung : _____________________________________
o Tenggorokan :_______________________________________

 LEHER
o Kelenjar Getah bening : ______________________________________
o Tiroid :
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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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 EKSTREMITAS
o Superior
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 o Inferior :
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 SALURAN KEMIH / GENITALIA

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 NEUROMUSKULAR
o Sensibilitas :
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o Kekuatan otot :
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o Refleks fisiologis :
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o Refleks Patologis :
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o Meningeal sign :
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II. PEMERIKSAAN PENUNJANG
A. Darah
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B. Radiologi
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C. Pemeriksaan penunjang lainnya

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III. RESUME
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IV. DIAGNOSIS BANDING

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V. DIAGNOSIS KERJA
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VI. PENATALAKSANAAN DAN PENGOBATAN

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VII. PEMERIKSAAN ANJURAN

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VIII. PROGNOSIS
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