KOMITE KOORDINASI PENDIDIKAN

FAKULTAS KEDOKTERAN UNIVERSITAS PALANGKARAYA

RSUD dr. DORIS SYLVANUS
MODUL ILMU KESEHATAN ANAK DAN REMAJA
Jl. Tambun Bungai no.04, Palangka Raya, 73112
Email : anak.fk.upr@gmail.com

DOKTER MUDA KEPANITERAAN KLINIK SMF/BAGIAN ILMU KESEHATAN ANAK DAN

REMAJA

Nama Mahasiswa : NIM :

Hari/Tanggal : Paraf :

STATUS PASIEN ANAK

I. IDENTITAS
1. Identitas Penderita
Nama penderita : .......................................................................................................................
Jenis kelamin : .......................................................................................................................
Tempat Tanggal Lahir : ................................................................. Umur : ....... Tahun ........ Bulan
2. Identitas Orang Tua/Wali
Ayah : Nama : .......................................................................................................................
Pendidikan : .......................................................................................................................
Pekerjaan : .......................................................................................................................
Alamat :.......................................................................................................................
Ibu : Nama : .......................................................................................................................
Pendidikan : .......................................................................................................................
Pekerjaan : .......................................................................................................................
Alamat : .......................................................................................................................

II. ANAMNESIS
Kiriman dari : .......................................................................................................................
Dengan diagnosis : .......................................................................................................................
Alloanamnesis dengan : .......................................................................................................................
Tanggal/Jam diperiksa : .......................................................................................................................
1. Keluhan Utama : .......................................................................................................................
Riwayat Penyakit Sekarang : (Secara kronologis, tiap masalah yang ditemukan diidentifikasi lengkap).
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2. Riwayat Penyakit Dahulu : (beri tanda centang pada penyakit yang pernah dialami)
Campak Diare Sesak
Batuk Rejan Kuning ISPA
TBC Cacingan Malaria Difteri Kejang DBD
Tetanus Demam Tifoid ...........
3. Riwayat kehamilan dan persalinan
- Riwayat Antenatal : .......................................................................................................................
- Riwayat Natal : .......................................................................................................................
- Nilai Apgar : .......................................................................................................................
- Berat Badan Lahir : .......................................................................................................................
- Panjang Badan lahir : .......................................................................................................................
- Lingkar Kapala : .......................................................................................................................
- Penolong : .......................................................................................................................
- Tempat : .......................................................................................................................
- Riwayat Neonatal : .......................................................................................................................
Kesan :

4. Riwayat Perkembangan
- Tiarap : ................................................................................................. Bulan/Tahun
- Merangkak : ................................................................................................. Bulan/Tahun
- Duduk : ................................................................................................. Bulan/Tahun
- Berdiri : ................................................................................................. Bulan/Tahun
- Berjalan : ................................................................................................. Bulan/Tahun
- Saat Ini Kesan : : ......................................................................................................................

5. Riwayat Imunisasi
Umur Pemberian (Bulan) Lokasi Pemberian Jaringan Parut
Jenis Imunisasi (IM/SC/Intrakutan, Anterolateral (Ada/Tidak)
Dasar Ulangan paha/Deltoid,dll)

Hepatitis B
Polio
BCG
DPT-Hep B-HiB
Campak-Rubella
 Kesan :

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6. Riwayat Pemberian Makan
Usia Jenis Makanan Kuantitas Kualitas

Kesan :

7. Riwayat Keluarga
*) Ikhtisar Keturunan : (Gambar skema keluarga dan beri tanda keluarga yang menderita penyakit sejenis. Untuk kelainan
kongenital usahakan skema yang lebih lengkap termasuk saudara sepupu dsb.)

Susunan Keluarga :
Jelaskan:
No. Nama Umur L/P
Sehat / Sakit (apa) / Meninggal (umur/Sebab)
1.
2.
3.
4.
5.
6.
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9.
10.
 7. Riwayat Sosial dan Lingkungan
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Kesan :

PEMERIKSAAN FISIK
1. Keadaan Umum : ..................................................................................................................................

Indikator BB//U PB (TB)//U BB//PB (TB) Nellhaus

(LK//U)
WHO-2006
CDC-2000
Waterlow
Kesan
Kesadaran : Compos mentis / Apatis / Somnolen / Stupor / Koma
GCS : ..................................................................................................................................

2. Pengukuran
Tanda Vital : Tensi : ...................... mmHg (P-90: …… ; P-95: …… ; P-99: ……)
Nadi : ...................... x/Menit
Suhu : ...................... oC
Respirasi : ...................... x/Menit

BB : ……………. Kg

PB (TB) : ……………..cm

LK : ……………. Cm
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LD : ……………. Cm

LLA : …………….. cm
LK/LD (hanya untuk > 1 th)

BMI : BB (kg) / TB (m2) :

…………………………...
Kesimpulan status gizi : Obesitas / Lebih / Baik / Kurang / Buruk

3. Kulit
Warna : ..................................................................................................................................
Sianosis : ..................................................................................................................................
Hemangioma : ..................................................................................................................................
Turgor : ..................................................................................................................................
Kelembapan : ..................................................................................................................................
Pucat : ..................................................................................................................................
Lain-lain : ..................................................................................................................................
4. Kepala
Bentuk : ..................................................................................................................................
UUB : ..................................................................................................................................
UUK : ..................................................................................................................................
Lain-lain : ..................................................................................................................................

Rambut
Warna : ..................................................................................................................................
Tebal/Tipis : ..................................................................................................................................
Distribusi : ..................................................................................................................................
Alopesia : ..................................................................................................................................
Lain-lain : ..................................................................................................................................
Mata
Palpebra : ..................................................................................................................................
Alis, Bulu Mata : ..................................................................................................................................
Konjungtiva : ..................................................................................................................................
Sklera : ..................................................................................................................................
Produksi air mata : ..................................................................................................................................
Pupil : Diameter : .................................................................................................................
Simetris : .................................................................................................................
Refleks : .................................................................................................................
Kornea : ..................................................................................................................................
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 Telinga

Bentuk : ..................................................................................................................................
Sekret : ..................................................................................................................................
Serumen : ..................................................................................................................................
Nyeri : .......................................................... Lokasi : ..........................................................

Hidung
Bentuk : ..................................................................................................................................
Pernapasan cuping hidung : .......................................................................................................................
Epistaksis : ..................................................................................................................................
Sekret : ..................................................................................................................................

Mulut
Bentuk : ..................................................................................................................................
Bibir : ..................................................................................................................................
Gusi : Mudah Berdarah / tidak
Pembengkakan + / -
Gigi geligi : ..................................................................................................................................

Lidah
Bentuk : ..................................................................................................................................
Pucat :+/-
Tremor :+/-
Kotor :+/-
Warna : ..................................................................................................................................

Faring
Hiperemi :+/-
Edema :+/-
Membran/Pseudomembran : + / -

Tonsil
Warna : ..................................................................................................................................
Pembesaran : ..................................................................................................................................
Abses :+/-
Membran/Pseudomembran : + / -

5. Leher
Vena Jugularis : Pulsasi :+/
Tekanan :
Pembesaran kelenjar leher : .......................................................................................................................
Kaku kuduk : .......................................................................................................................
Massa : .......................................................................................................................

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 Tortikalis : .......................................................................................................................

6. Thoraks
Dinding dada / Paru
Inspeksi : Bentuk : ...........................................................................................................
Retraksi : ........................................................................................................... Dispnea
: ...........................................................................................................
Pernapasan : ...........................................................................................................
Palpasi : Fremitus fokal : ...........................................................................................................
Perkusi : ...........................................................................................................
Auskultasi : Suara Napas dasar : ...............................................................................................
Suara Napas tambahan : ...............................................................................................

Jantung
Inspeksi : Ictus Cordis : ...........................................................................................................
Palpasi : Apeks : ...........................................................................................................
Thrill : ...........................................................................................................
Perkusi : Batas Kanan : ...........................................................................................................
Batas Kiri : ...........................................................................................................
Batas Atas : ...........................................................................................................
Auskultasi : Frekuensi : ...........................................................................................................
Suara dasar : ...........................................................................................................
Bising : .......................................... Derajat : ................................... Lokasi
: ................................... Punctum
Max : ................................... Penyebaran
: ...................................

7. Abdomen
Inspeksi : Bentuk : .......................................................................................................................
Lain-lain : .......................................................................................................................
Auskultasi :
Palpasi : Hati : .......................................................................................................................
Limpa : .......................................................................................................................
Ginjal : .......................................................................................................................
Massa : ................................................. Ukuran : ............................................
Lokasi : ............................................
Permukaan : ............................................
Konsistensi : ............................................
Nyeri : ............................................
Perkusi : Timpani / Pekak : ...........................................................................................................
Asites : ...........................................................................................................

8. Ekstremitas

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Umum : ...............................................................................................................................................
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9. Neurologis
Lengan Tungkai
No. Pemeriksaan
Kanan Kiri Kanan Kiri

1. Gerakan

2. Kekuatan

3. Tonus

4. Trofi

5. Klonus

6. Refleks Fisiologis

7. Refleks Patologis

8. Sensibilitas

9. Tanda Meningeal

10. Susunan Saraf : ...................................................................................................................................

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11. Genitalia : ...................................................................................................................................
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12. Anus : ...................................................................................................................................
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13. PEMERIKSAAN PENUNJANG 1.
Laboratorium
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2. Radiologi
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 3. Kuesioner Pra-Skrining Perkembangan (KPSP)
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III. RESUME
a. Anamnesis
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b. Pemeriksaan Fisik
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c. Pemeriksaan Penunjang
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IV. DIAGNOSIS
1. Diagnosis Kerja
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2. Diagnosis Banding
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 3. Diagnosis Gizi
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V. RENCANA PENGELOLAAN
1. Rencana Pemeriksaan
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2. Rencana Terapi
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3. Nutrisi dan Kebutuhan Cairan

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 4. Rencana Perawatan
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5. Rencana Edukasi
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VI. PROGNOSIS
Qua ad vitam : ................................................................................................................................... Qua ad
functionam : ................................................................................................................................... Qua ad
sanationam : ...................................................................................................................................
Revisi : Agustus 2021 10