KARTU

PENDERITA

Nama : Susanti

Alamat : Desa Mrican Rt 05 Rw 02

Sragi, Peka
Pekalongan
longan

PB MB
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KARTU PENDERITA KUSTA

Propinsi : JAW
JAWA
A TE!A" KLA
SIFI
KAS
#a$upaten % #ota : PEMA&A!

#eca'atan : ()DE"

Evalu
asi
hasil
peng
obata
n

KETERANGAN TENTANG PENDERITA

NAMA : Susanti ALAMAT : Desa

Mrican

JENIS KELAMIN : Perempuan DESA : Mrican

( Rt 02/ RW 02 

RIWAYAT PENYAKIT

KELAINAN PADA K!LIT DIKETA"!I SEJAK : # $ TA"!N $ % & TA"!N '&

CARA PENEMUAN
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 diisi dengan tanda  pada kotak terpilih

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PEMERIKSAAN AWAL
AWAL : Tgl 29 Juli 2016

PEMERIKSAAN KULIT DAN SARAF

GAMBARLAH
GAMBARLAH KELAINAN-KELA
KELAINAN-KELAINAN
INAN HASIL PEMERIKSAAN
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HASIL PEMERIKSAAN BAKTERIL!IK :

+ Pe'eriksaan $akteriologik an-a .ilakukan $ila SDM .an sarana terse.ia /

Tgl Lo#a Hasil :

peme"i#s si :
aan
Po
s:

$$ (upi
Agustus ng
%&$'
telin
ga
Kana
n

(upi
ng
telin
ga
Ki"i

Tan)
a )i
#ulit
:

 Tulis tanggal se*a"a leng#ap +

, tgl- bulan- tahun .

 Penga'$ilan .i cuping telinga : wa1i$

 Penga'$ilan .i kulit : pilila

$agian $ercak -ang paling akti 

 "in.ari penga'$ilan pa.a kulit wa1a

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PEN!BA
PEN!B ATAN /AN E0AL1
E0AL1ASI
ASI HASIL PEN!B
PEN!BAT
ATAN
AN :

Tanggal pembe"ian )osis M/T : $$ Agustus %&$'

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KEA/AAN (A(AT :
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Tanggal Mata
peme"i#s
Kan Ki
aan :
an "i

& &

A2
al

Saa
t
RF
T
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PEMERIKSAAN KNTA
KNTAK
K

SER1MAH

  UMUR

N"#"

N! L$ : P) :
$%&"$

'()u#"*

$ Men+i &2

2 Wi+3+3 6
Saputra

& 2
Rasm3na4

1 &2
 A-i
Darma5an

 &0

Tar3n3
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DA!TAR TI"IK PENYU"U#AN

Hal
-halyanghar
usdi
ket
ahuipender
ita.

 TENTANG PENYAKI
TKUSTA

 Apa itu pen-akit kusta

 Prose
Proses
s penularann-a

 Per1alana
Per1alanan
n pen-akitn-a
 TENTANG PENGOBATAN KUSTA
e

R  TENTANG REAKSI KUSTA

 Apa itu reaksi kusta

 #apan $isa ter1a.i reaksi

 Siapa -ang $isa 'engala'i reaksi

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Tan)a5tan)a )an ge4ala

Geala selanutnya : !a Tidak 

Batuk terus menerus

menerus 3 minggu
minggu
Dahak berdarah ?
Kecurigaan lain untuk TB ?

Atau trachoma ?
Diare berdarah / lendir ?
Bercak kulit yang
yang gatal ?
Scabies ?

 Bila ada jaw aban “YA” dari

da ri 7 tanda- tanda
di atas, teliti dahulu, obati seperluna!
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FORM EVALUASI PENGOBATAN

PREDNISON
Indikasi Pemberian Prednison Saran

Kesimpulan Pemberian
pemeriksaan: prednison :
3a ! ('dak
( dosis
1. Adakah
Adakah ber
bercak
cak yan
yangg eca
ecahh ! n"
n"d#$
d#$ee
tunggal)
yang ecah %
3a ! ('dak - 04 ,g )e$a,a & M'ngg#
&. Adak
Adakah
ah nye
nyer'
r' (ek
(ekan
an a
ada
da )ar
)ara*
a* %
3a ! ('dak - +4 ,g )e$a,a & M'ngg#
+. Aakah kek
Aakah kek#a(
#a(an
an "("
"("(( a(a#
a(a# ra)
ra)aa raba
raba
- &4 ,g )e$a,a & M'ngg#
berk# rang da$a,
da$a, -ak(#  dar' /
b#$an (erakh'r% 3a ! ('dak - 12 ,g )e$a,a & M'ngg#

0. Aakah ada $a
Aakah $ag"
g"(ha
(ha$,#
$,#)) yang
yang bar
bar## - 14 ,g )e$a,a & M'ngg#
(erad' da$a, -ak(#  dar' / b#$an
- 2 ,g )e$a,a
)e$a,a & M'ngg#
M'ngg#
(erakh'r %
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'angan Kaki

Tangga$ Ma(a 9ek#a(an 9e

Nyer' )ara* Gang
Gangg#
Lag"h 9#a g#an
an Ra)a
=ar' 2 Ib# ar Pe
Perge$ Ra)a
Tha$ Raba Per"ne#T'b.
) P")
(an "("( Raba
M#) 5('('k6

9a 9a 9a 9a 9a 9a 9a 9a

9' 9' 9' 9' 9' 9'

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Rea#si I :

$6  Jenis reaksi kusta

kusta :


%6  T
 Tanggal
anggal .iagnosa reaksi
reaksi :
6

76 (erlangsung $erapa la'a :



Rea#si II :

$6  Jenis reaksi
reaksi kusta :
66
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PEMERIKSAAN KLINIK ULANG

• &e'$ar ini .ise.iakan untuk 'encatat peru$aan3peru$aan tan.a3tan.a -ang

'ungkin .i1u'pai sela'a pengo$atan, saat R7T setela R7T, atau tentang pengo$atan
% asil pengo$atan -ang .i$erikan6

• 4atatla al3al -ang penting6

• Jangan mengubah gambar situasi awal pada halaman2.

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% 1ntu#
KARTU ,ER,AT MDT -
pengambilan
 obat )ilua"
pus#esmas
Nama : 777777777777777
77777777777777788
88 asal6

Ke-amin / !mur
!mur : L, :7778Pr: 77777
77777
Bliste"  Ti.ak perlu .iisi
#e $ila
/ibe"i#a
Pe,er9aan : 77777777777777 o$at .ia'$il .i
n )i
puskes'as asal6
pus#es
mas:
 A-amat : 7777877777777777
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 JADWA& MA
 JADWA& MATA PE&AJAR
PE& AJARA
A
#E&AS =A SMP  9
PETAR>#A
SENIN SELASA RABU
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IN/NESIA