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FAKULTAS KEDOKTERAN UKRIDA
(UNIVERSITAS KRISTEN KRIDA WACANA)
Jl. Terusan Arjuna no. 6 Kebon Jeruk Jakarta Barat
KEPANITERAAN DASAR
STATUS ILMU PENYAKIT DALAMFAKULTAS KEDKTERAN UKRIDA
RU!A" SAKIT # FA!IL$ !EDI%AL %ENTERNa&a # N'I A$U PUTRI Tan(a Tan)anNI! # **+,*-*6Dr. Pe&b/&b/n) # (r. !ars0ell Ten(ean1 S2.PD ..33333.
IDENTITAS PASIEN
Data Pasien
Nama A)us Set/a4anUmur -5 ta0un
Status Pera!inan Ka4/n"enis Ke#amin Lak/lak/
A#amat Sentul1 bo)orA$ama Isla&
Suu %an$sa Ja4aPen&i&ian S!APeer'aan Pe)a4a/ S4asta
ANAMNESIS
Ana&nes/s (/lakukan se7ara autoana&nes/s (en)an 2as/en 2a(a tan))al *, !aret
+,*81 2ukul *,.,, 9IB (/ Pol/ Pen:ak/t Dala&.
Ke#uan Utama
De&a& 0ar/ sebelu& &asuk ru&a0 sak/t
Ri!aat Penait Searan$
Sejak 0ar/ S!RS 2as/en &en)elu0 (e&a& t/n))/. De&a& :an) (/rasakan t/&bul
t/bat/ba1 t/(ak a(a &en))/)/l atau2un berker/n)at (/n)/n. De&a& &un7ul 2a(a &ala& 0ar/
se(an)kan 2a(a s/an) 0ar/ 2as/en &erasa leb/0 se)ar. Pas/en ju)a &erasa &ual ta2/ t/(ak
sa&2a/ &unta0. Pas/en &en)aku t/(ak &e&er/ksa bera2a su0u ba(ann:a saat (e&a&. T/(ak
a(a batuk1 t/(ak a(a 2/lek1 t/(ak a(a n:er/ &enelan. Pas/en ju)a &en)elu0 BAB kuran)
lan7ar. Su(a0 5 0ar/ S!RS 2as/en t/(ak BAB (an /n/ &en:ebabkan 2as/en ser/n) berasa t/(ak
1
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enak (/ba)/an 2erut se2ert/ 2erut ke&bun)1 BAK lan7ar k/rak/ra -; se0ar/1 seban:ak * )elas
bel/&b/n)1 t/(ak berbusa1 t/(ak a(a (ara01 (an t/(ak a(a 2as/r (an ber4arna kun/n) jern/0
serta tan2a n:er/.
5 0ar/ S!RS 1 2as/en teta2 (e&a& t/n))/ 2a(a &ala& 0ar/ t/(ak (/serta/ &en))/)/l
(an berker/n)at (/n)/n. Pas/en &erasa 2us/n) &erasa ber2utar (an &ata berkunan) kunan)1
(/serta/ &ual1 ke0/lan)an selera &akan (an t/(ak a(a &unta0. A(an:a n:er/ ulu 0at/ (an
2e)al (/seluru0 ba(an teta2 (/rasakan. A(an:a &/&/san (an )us/ ber(ara0 (/san)kal. Pas/en
ju)a t/(ak 2erna0 ber2er)/an ke luar (aera0. Pas/en su(a0 &/nu& 2ara7eta&ol tablet 8,, &)
se0ar/ t/)a kal/ sela&a + 0ar/1 2anas (/rasakan turun teta2/ na/k ke&bal/ setela0 + ja& &/nu&
obat.
Saat !RS1 2as/en &as/0 &erasa (e&a& 1 le&as1 berker/n)at 2a(a &ala& 0ar/1 a(a
&ual1 ke0/lan)an na ? %a7ar a/r = ? D/sentr/ = ? Burut ="ern/a?= ? D/
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Ri!aat Ke#uar$a
"ubun)an U&ur
=ta0un?
Jen/s
Kela&/n
Kea(aan
Kese0atan
Pen:ebab !en/n))al
Kakek Lak/ lak/ !en/n))al T/(ak (/keta0u/
Nenek Pere&2uan Se0at A:a0 C8 Lak/lak/ Se0at Ibu + Pere&2uan !en/n))al T/(ak (/keta0u/Sau(ara 8,
-8
Lak/lak/
Pere&2uan
Se0at
Se0at
Anakanak *C
Lak/lak/
Pere&2uan
Se0at
Se0at
A(aka0 Kerabat :an) !en(er/ta#
Pen:ak/t $a T/(ak "ubun)anAler)/ As&a Tuberkulos/s Art0r/t/s "/2ertens/ Jantun) @/njal La&bun)
Ri!aat Ke#airan
Te&2at la0/r # = ? D/ ru&a0 =? Ru&a0 Bersal/n = ? RS Bersal/nD/tolon) ole0 # = ? Dokter =? B/(an = ? Dukun
= ? La/nla/n
Ri!aat Imunisasi
=>? "e2at/t/s =>? B%@ => ? %a&2ak =>? DPT=>? Pol/o => ? Tetanus
Ri!aat Maanan
Frekuens/"ar/ # + kal/0ar/Ju&la0"ar/ # + 2ors/0ar/'ar/as/"ar/ # Buburt/(ak berar/as/
Na
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= ? SD = ? S!P = ? S!A = ? Sekola0 Kejuruan= ? Un/ers/tas = ? Kursus = ? Aka(e&/ = ? T/(ak sekola0
Kesu#itan
Keuan)an # Ba/k Pekerjaan # Ba/k Keluar)a # Ba/k La/nla/n #
PEMERIKSAAN FISIK
Kea(aan U&u&Kesan sak/t # Ta&2ak sak/t se(an)
Kesa(aran # %o&2os !ent/sKesan )// # Ba/k Kea(aan la/n # Ane&/s =?1 /kter/k =?1 s/anos/s =?
Pe&er/ksaan U&u&T/n))/ Ba(an # *6+ 7&Berat Ba(an # 68 k)Tekanan Dara0 # *5,, &&")
Na(/ # C- ;&en/tSu0u # 5C G%Perna
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Ke#en'ar +eta %enin$
Sub&an(/bula # T/(ak teraba &e&besar Le0er # T/(ak teraba &e&besarSu2rakla/kula# T/(ak teraba &e&besar Ket/ak # T/(ak teraba &e&besar
L/2at 2a0a # T/(ak teraba &e&besar
Ke*a#a
Eks2res/ 4aja0 # Nor&al1 4ajar S/&etr/ &uka # S/&etr/Ra&but # "/ta& Pe&bulu0 (ara0 te&2oral # Teraba 2ulsas/
Mata
E;o20t0ala&us # T/(ak a(a Eno2t0ala&us # T/(ak a(aKelo2ak # E(e&a =? Lensa # Jern/0Konjun)t/a # Ane&/s =? '/sus # T/(ak (/n/la/Sklera # Ikter/k =? @erakan !ata # Nor&al
La2an)an 2en)l/0atan # Nor&al Tekanan bola &ata # T/(ak (/2er/ksaDe/at/o Konju)ate # T/(ak a(a N/sta)&us # T/(ak a(a
Te#in$a
Tul/ # Sela2ut 2en(en)aran # Utu0Luban) # >> Pen:u&batan # T/(ak a(aSeru&en # Pen(ara0an # T/(ak a(a%a/ran #
Mu#ut
B/b/r # T/(ak ker/n) Tons/l # T*T*tenan)Lan)/tlan)/t # T/(ak ber7ela0 Bau 2erna2asan # T/(ak k0as@/)/ )el/)/ # T/(ak 7ar/es Tr/s&us # T/(ak a(aFar/n) # T/(ak 0/2ere&/s Sela2ut len(/r # Nor&alL/(a0 # Se(/k/t kotor
Leer
Tekanan 'ena Ju)ular/s =J'P? # 8+ 7& "+Kelenjar T/ro/( # T/(ak ta&2ak &e&besar Kelenjar L/&
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Kanan T/(ak a(a benjolan T/(ak n:er/ tekan Fre&/tus takt/l s/&etr/s
T/(ak a(a benjolan T/(ak n:er/ tekan Fre&/tus takt/l s/&etr/s
Perkus/ K/r/ Sonor (/ seluru0 la2an) 2aru Sonor (/ seluru0 la2an) 2aruKanan Sonor (/ seluru0 la2an) 2aru Sonor (/ seluru0 la2an) 2aru
Auskultas/ K/r/ Suara es/kuler 90ee/n) =?1 Ronk/ =?
Suara es/kuler 90ee/n) =?1 Ronk/ =?
Kanan Suara es/kuler 90ee/n) =?1 Ronk/ =?
Suara es/kuler 90ee/n) =?1 Ronk/ =?
"antun$
Ins2eks/ # T/(ak ta&2ak 2ulsas/ /7tus 7or(/sPal2as/ # Teraba /7tus 7or(/s 2a(a sela /)a ' (/ l/nea &/(kla/kula k/r/Perkus/ # Batas kanan # sela /)a ' l/nea sternal/s kanan
Batas k/r/ # sela /)a '1 *7& sebela0 &e(/al l/nea &/(kla/kula k/r/ Batas atas # sela /)a II l/nea 2arasternal k/r/
Auskultas/ # Bun:/ jantun) III &urn/ re)uler1 @allo2 =?1 !ur&ur =?.
Pem-u#u Dara
Arter/ Te&2oral/s # Teraba 2ulsas/Arter/ Karot/s # Teraba 2ulsas/Arter/ Brak0/al/s # Teraba 2ulsas/Arter/ Ra(/al/s # Teraba 2ulsas/Arter/ Fe&oral/s # Teraba 2ulsas/Arter/ Po2l/tea # Teraba 2ulsas/Arter/ T/b/al/s Poster/or # Teraba 2ulsas/
Arter/ Dorsal/s Pe(/s # Teraba 2ulsas/A-&.men
Ins2eks/ # S/&etr/s1 (atar1 benjolan =?Pal2as/ #
D/n(/n) 2erut # su2el1 n:er/ tekan e2/)astr/u& =>?
"e2ar # t/(ak teraba 2e&besaranL/en # t/(ak teraba 2e&besaran@/njal # Ballote&ent =?1 n:er/ ketok %'A =?Kan(un) e&2e(u # !ur20:Hs s/)n =?
Perkus/ # t/&2an/1 s0/? nor&o2er/stalt/k Re
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!assa Nor&al nor&alSen(/ n:er/ =? N:er/ =?@erakan Akt/< akt/< Kekuatan >8 >8e(e& =? =?
La/nla/n # Ru&2le Lee( *, =? *, =?
Tun$ai &an Kai
Kanan K/r/Luka T/(ak a(a T/(ak a(a'ar/ses T/(ak a(a T/(ak a(atotTonus Nor&otonus nor&otonus!assa Nor&al nor&al
Sen(/ n:er/ =>? n:er/ =>?@erakan Akt/< akt/< Kekuatan >8 >8e(e&a =? =?La/nla/n # 2ete70/e *, =? *, =?
Re/#es
C.#. Du-ur
T/(ak (/lakukan
PEMERIKSAAN PENUN"AN+
La-.rat.rium &ara rutin
"b # ** )(lLeukos/t # *-,,,&&5"t # 5 Tro&bos/t # 5-.,,,uL
Tes Wi&a#
7
Kanan K/r/
Re
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S.t:20/ # *56,S.2arat:20/ A # **6,S.2arat:20/ B # **6,S.2arat:20/ % # *C,
RIN+KASAN (RESUME)
Tn. A.S1 -5 ta0un &en)elu0 2anas sejak 0ar/ S!RS :an) (/rasakan 2a(a &ala&
0ar/1 berker/n)at (/n)/n1 &ual1 (an na
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PEMERIKSAAN YAN+ DIAN"URKAN
Pe&er/ksaan (ara0 te2/ Pe&er/ksaan ur/n len)ka2 Pe&er/ksaan t/nja rut/n
Pe&er/ksaan bakter/olo)/s (en)an /solas/ (an b/akan ku&an Uj/ serolo)/s # I)& S.t:20/1 t:20/ (ot
RENCANA PEN+ELOLAAN
N.n,Farma.#.$is 0
T/ra0 bar/n) &/n/&al 0ar/D/et &akanan lunak1 t/n))/ kalor/1 /ta&/n (an 2rote/n1 serta t/(ak &en)an(un)
ban:ak serat
Konsu&s/ 7a/ran :an) &e7uku2/B/la "b terlalu ren(a0 (an a(a tan(atan(a (eko&2ensas/ 7or(/s1 trans
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I&un/sas/ (en)an &en))unakan aks/n oral (an aks/n sunt/kan =ant/)en '/Pol:sa770ar/(a 7a2ular?1 70ot/2a =70olerat/