STATUS PASIEN

I.
IDENTITAS
1. Nama lengkap
: ..........................................................................................................
..
2. Jenis Kelamin
: Laki-laki / Perempuan
3. Umur
: .........................Tahun,
............................Bulan, ..........................Hari
4. Suku / Bangsa
:................................................... / .....................................................
..
5. Agama
: Islam / Kristen / Katolik / Hindu /
Budha / ....................
6. Pekerjaan
: .....................................................................................
.......................
7. Alamat
: ...........................................................................
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.......................
8. Status Perkawinan : Kawin / Belum Kawin / Duda / Janda
II.
ANAMNESIS
1. Keluhan Utama :................................................
2. Riwayat Penyakit Sekarang
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3. Riwayat Penyakit Dahulu :
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4. Riwayat Penyakit Keluarga :
1

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5. Riwayat Sosial Ekonomi :
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6. Kebiasaan :
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III.
PEMERIKSAAN FISIK
1. Kesan
umum : ...............................................................................................
..............................
2. Keadaan
sakit:...................................................................................................
...........................
3. Tanda Vital
a. Kesadaran
: ..........................
b. Tekanan darah : ......................... mmHg
c. Nadi
: ........................ x /mnt, irama: ....................... , isi
..........................
d. Laju Nafas
: ........................ x /menit,
tipe ............................................
e. Suhu
: ....................... c
4. Pemeriksaan Per Organ
a. Kulit
: warna kulit........................., sianosis ( ), dekubitus ( )
b. Kepala
: bentuk, nyeri tekan ( )
c. Mata
: konjunctiva anemis ( / ), sklera ikterik ( / ), katarak ( / )
d. Telinga
: sekret ( )
e. Hidung
: sekret ( ), deviasi septum ( )
f. Mulut
: bibir sianosis ( ), lidah kotor ( ), tonsil T.../T...
g. Leher
: pembesaran limfonodi ( ),
di..............................................................
kaku kuduk ( ), deviasi trakea ( ) ke..........,
bendungan JVP ( )
h. Jantung

Inspeksi
: iktus kordis...............................

Palpasi
: iktus kordis teraba di SIC.....
linea....................................................

Perkusi
: Batas kiri jantung: SIC....
linea.........................................................
2

Batas kanan jantung: SIC....

linea....................................................
Batas atas jantung: SIC....
linea.......................................................
Pembesaran
jantung:......................................................................

Auskultasi: bunyi jantung I/II................., bising ( ), gallop ( )

i.

Abdomen

Inspeksi
: bentuk, venektasi
( ),.....................................................................

Auskultasi : bising usus

(......./menit).................................................................

Palpasi
: nyeri tekan ( ),
di............................................................................
Hepar................................,lien...........................,undula
si( )

Perkusi
: ascites ( ), timpani
( ),....................................................................

j.

IV.

Ekstremitas
: oedema ( ), sianosis ( ), jari tabuh ( ), capillary
refill (.... 2 detik),
tremor ( )

STATUS LOKALIS
Thoraks
: bentuk
dada.......................................................................................
Paru
Inspeksi : Statis
:.............................................................
Dinamis :...........................................................
Palpasi
: Stem
fremitus.....................................................................................
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Perkusi
: ................................................................................................
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Auskultasi
: suara napas
pokok..............................................................................
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Wheezing ( / ),
di.................................................................................
Rhonki
( / ).....................,di..................................................................
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.......................

V. PEMERIKSAAN PENUNJANG

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VI. RESUME

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VII. DIAGNOSA SEMENTARA/TETAP

1. ........................................................................
2. .
3. .
4

VIII.

DIAGNOSA BANDING:
1. ........................................................................
2. .
3. .

IX.

TERAPI/TATALAKSANA :
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USULAN PEMERIKSAAN PENUNJANG :
1. ...............................................................................................
2. ...............................................................................................
3. ...............................................................................................
4. ...............................................................................................
5. ...............................................................................................

X.

XI.

PROGNOSIS
Ad Vitam
:.....................................................................
Ad functionam :.....................................................................
Ad Sanactionam
:.....................................................................