GERIATRI ASESMEN SINGKAT
4
FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNG PURA/RSUD.DR.SOEDARSO PONTIANAK ASESMEN GERIATRI No.RM (RAWAT JALAN, MINI-CEX) Nama : ………………………………………………………………………………………………… Laki-laki/Perempuan Umur : …………………….. Th Agama : Islam/Katolik/Kristen/Hindu/Budha Pendidikan : Tidak sekolah/SD/SMP/SMA/D3/S1/S2/S3 Alamat/Hp : ………………………………………………………………………………………………………………………………….. Pekerjaan : ………………………………………………………………………………………………………………………………….. A.ANAMNESIS: 1. Keluhan Utama : ………………………………………………………………………………………………………, …………….. Riwayat Penyakit sekarang : . …………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………….... ……………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………….... Riwayat penyakit dahulu: ………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………………………………………… ………………….. ……………………………………………………………………………………………………………………………………………………... ……………………………………………………………………………………………………………………………………………………. 2. Kebiasaan : Ya Tidak Jumlah Merokok …………………… …………………… ………………………….. perhari Minum alkohol …………………… …………………… ………………………….. perhari Minum kopi …………………… …………………… ………………………….. perhari Olahraga (jenis/intensitas) ………………………………………………………………………………………………............. ……………………………………………………………………………………………………………………………………….............. Dengan resep dokter Dosis dan lama pemakaian ………………………………………………………. ………………………………………………………………………............. ………………………………………………………. ………………………………………………………………………............. ………………………………………………………. ………………………………………………………………………............. Tanpa resep dokter Dosis dan lama pemakaian ………………………………………………………. ………………………………………………………………………............. IDENTITAS PASIEN
-
Upload
abang-keluang -
Category
Documents
-
view
20 -
download
0
description
GERIATRI ASESMEN SINGKAT
Transcript of GERIATRI ASESMEN SINGKAT
FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNG PURA/RSUD.DR.SOEDARSOPONTIANAK
ASESMEN GERIATRI No.RM
(RAWAT JALAN, MINI-CEX)
Nama : ………………………………………………………………………………………………… Laki-laki/PerempuanUmur : …………………….. ThAgama : Islam/Katolik/Kristen/Hindu/BudhaPendidikan : Tidak sekolah/SD/SMP/SMA/D3/S1/S2/S3Alamat/Hp : …………………………………………………………………………………………………………………………………..Pekerjaan : …………………………………………………………………………………………………………………………………..
A. ANAMNESIS:1. Keluhan Utama : ………………………………………………………………………………………………………,……………..
Riwayat Penyakit sekarang : .………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………….... …………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………....Riwayat penyakit dahulu:…………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………….
2. Kebiasaan : Ya Tidak JumlahMerokok …………………… …………………… ………………………….. perhariMinum alkohol …………………… …………………… ………………………….. perhariMinum kopi …………………… …………………… ………………………….. perhariOlahraga (jenis/intensitas)……………………………………………………………………………………………….............……………………………………………………………………………………………………………………………………….............. Dengan resep dokter Dosis dan lama pemakaian………………………………………………………. ……………………………………………………………………….............………………………………………………………. ……………………………………………………………………….............………………………………………………………. ………………………………………………………………………............. Tanpa resep dokter Dosis dan lama pemakaian………………………………………………………. ……………………………………………………………………….............………………………………………………………. ……………………………………………………………………….............
B. PEMERIKSAAN FISIK:1. Kesan Umum………………………………………………………………………………….......2. Tanda vital
Kesadaran : Kompos mentis/apatis/somnolen/sopour/coma/………………………. Baring Duduk Berdiri
Tekanan darah (TD)* ………………….. …………………….. ………………………….. Nadi/menit ………………….. …………………….. ………………………….. Laju respirasi/menit ………………….. …………………….. …………………………..
(*ukur TD setelah 2 menit pada posisi tersebut) Suhu ……………………derajat Celcius
3. Tanda-tanda pentinga. Sindrom Geriatri
.........................................................................................................................................b. Gejala –gejala penting
.........................................................................................................................................
.........................................................................................................................................
IDENTITAS PASIEN
FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNG PURA/RSUD.DR.SOEDARSOPONTIANAK
ASESMEN GERIATRI No.RM
(RAWAT JALAN, MINI-CEX)
c. Kelainan fisik penting..............................................................................................................................................................................................................................................................................................................................................................................................................................
d. Kelainan psikologik....................................................................................................................................................................................................................................................................................
C. DIAGNOSIS
C1.Geriatri :……………………………………………………….......................................................................
C2.Patologis:.………………………………………………..... ………………….................................................
..…………………………………………………... ...................................................................
.......................................................... ..................................................................
C3.Psikologis:....................................................... ...................................................................
D.GANGGUAN
1………………………………………………………............ 3.…………………………………………………………………
2..................................................................... 4.....................................................................
E. KETIDAK MAMPUAN 1...................................................................... 3.....................................................................
. 2...................................................................... 4.....................................................................
F.HAMBATAN
1……………………………………………………… 3.……………………………………………………………………………
2..…………………………………………………… 4.……………………………………………………………………………
G.TATALAKSANA
1. Non Medikamentosa ………………………………..……………………………………………………………… ……………………………………………………………………..……………………………………………………………… ……………………………………………………………………..………………………………………………………………
2. Medikamentosa …………………………………………………………………..…………………………………… ……………………………………………………………………..……………………………………………………………… …………………………………………………………………………………………………………………………………….
F. REKOMENDASI
…………………….………………………………………………………………………....................................... ………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………..
PONTIANAK, …………………………
Pembuat Asesmen
(………………………………….)
