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KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

FAKULTAS KEDOKTERAN UNIVERSITAS PATTIMURA
Bag./SMF Ilmu Kesehatan Kulit dan Kelamin FK-UNPATTI/RSUD dr. M. Haulussy

STATUS PENDERITA

DIAGNOSIS : _______________________________________________

NAMA : ________________________________________
NIM : ________________________________________
PEMBIMBING : ________________________________________

) Jantung/Paru : _______________________________________________________________________ Abdomen : _______________________________________________________________________ Ekstremitas : _______________________________________________________________________ Kelenjar Limfa : _______________________________________________________________________ 4. Status Presens Keadaan Umum : Sakit (Ringan/Sedang/Berat) . Anamnesis : Autoanamnesis/ Heteroanamnesis Keluhan Utama : _______________________________________________________________________ Anamnesis Terpimpin : _______________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 3. Bokong. Ekstremitas (superior/inferior) . Punggung. Status Lokalis : Kepala. Masuk RS/Klinik : _______________________________________________________________________ 2. Higiene (Buruk/Sedang/Baik) Tanda vital : Tensi _________________ mmHg . Dada.) * Bibir : sianosis ( +/ . Nadi ________________ x/menit Pernapasan _____________ x/menit . Kesadaran : _____________________ Gizi (Kurang/Cukup/Baik) . Genitalia. Suhu ______________ °C Kepala : * Sclera : icterus ( +/ . Nama : _______________________________________________________________________ Umur : _______________________________________________________________________ Alamat : _______________________________________________________________________ Status Perkawinan : _______________________________________________________________________ Tgl.) * Konjunctiva : anemia ( +/ .1.

Diskusi : _______________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ . Laboratorium Kerokan : _______________________________________________________________________ _______________________________________________________________________ Dan lain-lain : _______________________________________________________________________ _______________________________________________________________________ 7. Diagnosis Banding : _______________________________________________________________________ _______________________________________________________________________ 9.5. Resume : _______________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 8. Diagnosis : _______________________________________________________________________ 10. Status Dermato-Venereologi Lokasi : _______________________________________________________________________ Ukuran : _______________________________________________________________________ Efloresensi : _______________________________________________________________________ 6.

Terapi Sistemik : _______________________________________________________________________ _______________________________________________________________________ Topikal : _______________________________________________________________________ _______________________________________________________________________ 13. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 11. Prognosis : _______________________________________________________________________ _______________________________________________________________________ Pembimbing ______________________________________ . Anjuran Pemeriksaan : _______________________________________________________________________ _______________________________________________________________________ 12.

LEMBAR FOLLOW UP PASIEN BANGSAL Hari/Tanggal Follow up .