RUMAH SAKIT DORIS

SYLVANUS/ DEPARTEMEN ILMU PENYAKIT DALAM

UNIVERSITAS
PALANGKARAYA STATUS PASIEN
FAKULTAS
Untuk Dokter Muda
KEDOKTERAN
Nama Dokter Muda Tanda Tangan
NIM
Tanggal
Rumah sakit
Gelombang Periode

I. IDENTITAS
Nama : ...................................................................................................................
Umur : ...................................................................................................................
Jenis Kelamin : ...................................................................................................................
Agama : ...................................................................................................................
Pendidikan Terakhir : ...................................................................................................................
Alamat : ...................................................................................................................
Tanggal Pemeriksaan : ...................................................................................................................
Ruangan : ...................................................................................................................
MRS : ....................................................................................................................

II. ANAMNESIS
Keluhan Utama: ................................................................................................................................

Riwayat Penyakit Sekarang: .............................................................................................................

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 Riwayat Penyakit Terdahulu:
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Riwayat Penyakit Keluarga: ..............................................................................................................

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III. PEMERIKSAAN FISIS

Keadaan Umum : ...............................................................................................................................
Kesadaran : ...............................................................................................................................
BB: ………. Kg TB: ………. Cm IMT: ………. Kg/m2

 Vital Sign
Tekanan Darah : ………………. mmHg Suhu : ………. ℃
Pernapasan : ………. Kali/Menit Nadi : ………. Kali/Menit

 Kepala
Bentuk :
Mata :
Telinga :
Hidung :
Mulut :

 Leher
 Kelenjar GB : .................................................................................................................................
Tiroid : .................................................................................................................................
JVP : .................................................................................................................................
Massa lain : .................................................................................................................................

 Thorax
a) Paru-Paru

◦ Inspeksi : .............................................................................................................................

◦ Palpasi : .............................................................................................................................

◦ Perkusi : .............................................................................................................................

◦ Auskultasi : .............................................................................................................................

b) Jantung
◦ Inspeksi : .............................................................................................................................
◦ Palpasi : .............................................................................................................................
◦ Perkusi : .............................................................................................................................

◦ Auskultasi : .............................................................................................................................

 Perut
◦ Inspeksi : .................................................................................................................................
◦ Auskultasi : .................................................................................................................................
◦ Palpasi : .................................................................................................................................
◦ Perkusi : .................................................................................................................................
 Anggota Gerak
◦ Atas : .................................................................................................................................

◦ Bawah : .................................................................................................................................

IV. DAFTAR MASALAH

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V. Analisis Masalah

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VI. KRITERIA DIAGNOSIS
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VII . ASSESMENT
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VIII. DIAGNOSIS BANDING

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IX . TERAPI

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X. MONITORING
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XI . EDUKASI

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XIII. PROGNOSIS
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Palangka Raya, 2018

Dokter Muda

(…………………………………………….…)
NIM. FAA …………………….