STATUS PASIEN 1. Identitas Nama:_________________________________________Tgl. Lahir/Umur:_________________________________________Jenis Kelamin:_________________________________________Alamat:_________________________________________Tgl. Masuk RS:_________________________________________Identitas Orang TuaAyah Ibu

Nama

Umur

Pendidikan terakhir

Pekerjaan

2. Anamnesis a. Keluhan Utama:_________________________________________

b. Riwayat Penyakit Sekarang:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________c. Riwayat Penyakit Dahulu:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________d. Riwayat Penyakit Keluarga:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________e. Genogram:

f. Riwayat Kehamilan dan Persalinan:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________g. Riwayat Makan:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________h. Riwayat Imunisasi:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________i. Riwayat Tumbuh-Kembang:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________j. Riwayat sosioekonomi dan Lingkungan: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. Anamnesis Sistema. SSP:_________________________________________b. Kardiovaskuler:_________________________________________c. Respirasi:_________________________________________d. Gastrointestinal:_________________________________________e. Genitourinaria:_________________________________________f. Muskuloskeletal:_________________________________________g. Integumen:_________________________________________h. Termoregulasi:_________________________________________

4. Pemeriksaan FisikKesan umum: _________________________________________AntopometriBB : BB/U:

TB/PB :TB/U:

LLA :

LK :

Tanda-tanda Vitala. Nadi:_______________________________________________b. Suhu:_______________________________________________c. TD:_______________________________________________d. Respirasi:_______________________________________________Status generalisataa. Kepala: normocephalb. Mata: Konjungtiva anemis (__), sklera ikterik (__), c. Telinga: Simetris, sekret (_/_), nyeri tekan (_/_)d. Hidung: deviasi septum (__), nyeri tekan (__), sekret (__).e. Tenggorokan : tonsil (T_/T_), hiperemis (__), dedritus (__)f. Leher : Pembesaran KGB (__), Nyeri Tekan (__), JVP (__) g. Paru: Inpeksi: simetris (_), retraksi (_)Palpasi:fremitus taktil kanan (___) kiriPerkusi : sonor (__)________________________________Auskultasi: SND vesikuler, Ronki (__/__), Wheezing (__/__)h. Jantung: Inspeksi: ictus codis tidak terlihatPalpasi: IC teraba di SIC V linea midklavikula sinistraPerkusi : batas jantung normalAuskultasi: S1 tunggal, S2 split tak konstan, reguler, gallop (__), murmur (__)i. Abdomen: Inspeksi: Distensi (__), keras seperti papan (__)Auskultasi: Bising usus (__) normalPerkusi: _________________________________________Palpasi: hepar (_) dan lien (_)________________________j. Ekstremitas: sianosis (_), edema (_), akral dingin (_), CRT___2,5. Pemeriksaan Penunjang__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. Diagnosis:Fungsional:_______________________________________________Etiologi:_______________________________________________Anatomi:_______________________________________________Lain-lain:_______________________________________________7. Diagnosis Banding:_______________________________________________________________________________________________________________________8. Tatalaksana:Medikamentosa Nonmedikamentosa