STATUS PASIEN BAGIAN ILMU KESEHATAN DAN MATA

P3D FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM BANDUNG

NAMA : UMUR :

ANAMNESIS RUANGAN : NO. REG :

TANGGAL :

- KELUHAN UTAMA

- ANAMNESE KHUSUS
-
RIWAYAT PENYAKIT YANG LALU

- ANAMNESE KELUARGA

- RIWAYAT GIZI

- KEADAAN SOSIAL EKONOMI

- PENYAKIT SISTEMIK
- TRACT RESPIRASI
- TRACT DIGESTIVE
- CARDIO VASKULAR
- EKDOKRIN
- NEUROLOGY
- KULIT
- T.H.T
- GIGI DAN MULUT
- LAIN-LAIN

I PEMERIKSAAN UMUM
- TINGGI BADAN :
- BERAT BADAN :
- TEKANAN DARAH :
- NADI :
- SUHU :
- PERNAPASAN :
- CARDIOVASKULAR :
- G.I. TRACT :
- PARU-PARU :
- NEUROLOGY :
II. PEMERIKSAAN VISUS DAN REFRAKSI

- VISUS : SC : ……………………………PH…………………....... ……….………………………………PH………………………….....

CC : ……………………………………………………….. ……...…………………………………………………………………..
STEN : ……………………………………………………….. …………………………………………………………………………..

- KOREKSI : S………. C………….. as…….. S……. C…………. as………

: Add : S Add : S
:

- MUSCLE BALANCE :…………………………………………………………… …………………………………………………………………………..

PERGERAKAN BOLA MATA :……………………………………………… …………………………………………………………………………..
………………………………………………. …………………………………………………………………………..

III. PEMERIKSAAN EXTERNAL

- PALPEBRA SUP : …………………………………………... …………………………………………………………………………..

- PALPEBRA INP : …………………………………………… …………………………………………………………………………..
- CILIA : …………………………………………… …………………………………………………………………………..
- AP. LACRIMARIS : …………………………………………… …………………………………………………………………………..
- CONY. TARS SUP : …………………………………………… …………………………………………………………………………..
- CONY. TARS INP : …………………………………………… …………………………………………………………………………..
- CONY. BULBI : …………………………………………… …………………………………………………………………………..
- CORNEA : …………………………………………… …………………………………………………………………………..
: …………………………………………… …………………………………………………………………………..
- KAMAR DEPAN : …………………………………………… ……………………………………………………………………………
- PUPIL : …………………………………………… ……………………………………………………………………………
- DIAMETER : …………………………………………… ……………………………………………………………………………
- REFLEX CAHAYA : …………………………………………… ……………………………………………………………………………
- Direct : …………………………………………… ……………………………………………………………………………
- Konsensuil : …………………………………………… …………………………………………………………………………..
- IRIS : …………………………………………… …………………………………………………………………………..
- LENSA : …………………………………………… …………………………………………………………………………..
- LAIN-LAIN : …………………………………………… …………………………………………………………………………..

IV. PEMERIKSAAN SLIT LAMP DAN BIMICROSCOPY

O.D. O.S.
- CILIA : ……………………………………………………………………... ………………………………………………………………
- CONYUNCTIVA : ……………………………………………………………………… ……………………………………………………………..
- CORNEA : ………………………………………………………………………. ………………………………………………………………
- KAMAR DEPAN : ……………………………………………………………………… ……………………………………………………………..
- IRIS : ……………………………………………………………………… ……………………………………………………………..
- LENSA : ……………………………………………………………………… ……………………………………………………………..
-
V. TONO METRI

- PALPASI : ……………………………………………………………………… ……………………………………………………………..

- SCHIOTZ : ……………………………………………………………………… ………………………………………………………………

VI. GONIOSCOPY : …………………………………………………………………….. ……………………………………………………………..

: …………………………………………………………………….. ……………………………………………………………..

VII. VISUAL FIELD : …………………………………………………………………….. ……………………………………………………………..

: …………………………………………………………………….. ……………………………………………………………..
VIII. PEMERIKSAAN PADA KEADAAN MIDRIASIS

FUNDUSKOPI
- MEDIA : ………………………………………………………… ……………………………………………………………………..
- PAPIL : .................................................................. .......................................................................
- A/V RATIO : ………………………………………………………… ……………………………………………………………………..
- C/D RATIO : ………………………………………………………… ……………………………………………………………………..
- RETINA : ………………………………………………………… ……………………………………………………………………..
- MACULA : ………………………………………………………… ……………………………………………………………………..

IX PEMERIKSAAN LAIN-LAIN ………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………

X. RESUME : ……………………………………………………………………………………………………………………………………………………………......
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................

XI. DIAGNOSE KERJA : …………………………………………………………………………………………………………………………………......

XII. DIFERENSIAL DIAGNOSIS :
……………………………………………………………………………………………………………....................................................................................
...............................................................................................................................................................................................................
..............................................................................................................................................................................................................
XIII. RENCANA PEMERIKSAAN :
……………………………………………………………………………………………………………………………………….....................................................
..............................................................................................................................................................................................................
..............................................................................................................................................................................................................
..............................................................................................................................................................................................................
..............................................................................................................................................................................................................
XIV. RENCANA THERAPY : …………………………………………………………………………………………………………………………………………
: …………………………………………………………………………………………………………………………………………..
: …………………………………………………………………………………………………………………………………………..
: …………………………………………………………………………………………………………………………………………..
: …………………………………………………………………………………………………………………………………………..
: …………………………………………………………………………………………………………………………………………..
XV. RENCANA OPERASI : ………………………………………………………………………………………………………………………………………
XVI. PROGNOSA : …………………………………………………………………………………………………......................................
: …………………………………………………………………………………………………......................................
: …………………………………………………………………………………………………......................................

NAMA KOAS :

NPM :

KEGIATAN :

PRESEPTOR :