STATUS POLIKDOKTER MUDA BAGIAN BEDAH

Hari/ Tanggal: ...........................................Nama Coass: ..............................................

I. IDENTITASNama :Umur :Jenis Kelamin :Berat Badan :Agama :Pekerjaan :Alamat 014 :

II. ANAMNESAA. Keluhan Utama:

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B. Riwayat Penyakit sekarang : ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

C. Riwayat Penyakit Dahulu:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

III. PEMERIKSAAN FISIK- Tanda – tanda Vital : TD : Respirasi :

Nadi : Suhu :- Kepala : .................................................................................................................................................. - Leher : ..................................................................................................................................................- Thorax : ...................................................................................................................................................

..................................................................................................................................................- Abdomen : ..................................................................................................................................................

.................................................................................................................................................. .- Extremitas : ..................................................................................................................................................- Genitalia : ...................................................................................................................................................

KEMENTRIAN PENDIDIKAN NASIONALFK. UNIVERSITAS CENDERAWASIH / RSUD JAYAPURA

BAGIAN BEDAHJl. Kesehatan No. 01 . 533616,533516 Fax (0967) 533781

- Status Lokalis : ............................................................................................................. Gambar ................................................................................................................

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IV. DIAGNOSIS KERJA :......................................................................................................................................................................................................................

V. DIAGNOSIS BANDING :................................................................................................................................................................................................................................................................................................................................................

VI. PLANNING :