Hasil Laboratorium

LAMPIRAN
01

REKAM MEDIS
FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA

Nama keluarga: Nama: Umur: J. kelamin: No. Rekam Medis:

[ ] Lk [ ] Pr
Alamat tetap: No. Telp:
Kel. Kec. RT RW Kota
Tanggal lahir: Tempat lahir: Agama: Suku:
[ ] Islam [ ] Kristen Protestan [ ] Katolik [ ] Hindu [ ] Budha
No.KTP/SIM/PASPOR: Golongan darah: Status pernikahan: Pendidikan terakhir:
[ ] A [ ] B [ ] AB [ ] O [ ] Nikah [ ] Belum nikah [ ] Tidak sekolah [ ] SD [ ] SMP [ ] SMA
[ ] Janda [ ] Duda [ ] Akademi [ ] Perguruan Tinggi
Pekerjaan: Alamat pekerjaan:

Alamat lengkap sementara di Jakarta: No. Telp:

Kel. Kec. RT RW Kota
Dikirim oleh:

Dokter yang memeriksa: Ko-asisten: Tanggal pemeriksaan:

Anamnesis
ANAMNESIS
(Pasien sendiri/orang lain, hubungan: ..........................................................................)

KeluhanUTAMA
KELUHAN Utama
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Riwayat
RIWAYAT Penyakit
PENYAKIT Sekarang
SEKARANG
(termasuk keluhan tambahan, data pemeriksaan dan pengobatan sebelumnya)
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Riwayat Penyakit
RIWAYAT PENYAKIT Terdahulu
DAHULU

Riwayat Penyakit Dahulu (tanggal/tahun)

[ ] Cacar [ ] Tuberkulosis [ ] Batu empedu

[ ] Cacar air [ ] Malaria [ ] Batu ginjal/saluran kemih

[ ] Difteria [ ] Disentri [ ] Burut (hernia)

[ ] Batuk rejan [ ] Hepatitis [ ] Penyakit prostat

[ ] Campak [ ] Tifus abdominal [ ] Wasir

[ ] Influensa [ ] Skrofula [ ] Diabetes

[ ] Tonsilitis [ ] Gonorea [ ] Tumor

[ ] Kornea [ ] Sifilis [ ] Alergi

[ ] Demam reumatik akut [ ] Hipertensi [ ] Penyakit pembuluh darah otak

[ ] Pneumonia [ ] Ulkus ventrikuli [ ] Psikosis

[ ] Pleuritis [ ] Ulkus duodeni [ ] Neurosis

[ ] Gastritis [ ] Lain-lain:
- [ ] Operasi
- [ ] Kecelakaan
Tuliskan catatan riwayat penyakit terdahulu berupa tanda ( √ ) di samping judul yang bersangkutan dan tuliskan tanggal/tahunnya.

RIWAYAT PENYAKIT KELUARGA

Riwayat Penyakit Keluarga
Riwayat Penyakit Keluarga
Hubungan Umur Sex Kesehatan Meninggal Penyakit Hubungan
(Penyebab)
Kakek
Nenek
Ayah
Ibu
Saudara

Anak

Genogram
GENOGRAM

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Anamnesis Sistem
ANAMNESIS SISTEM

Anamnesis Sistem
Kulit
Kulit
[ ] Bisul [ ] Kuku [ ] Rambut [ ] Lain-lain

Kepala
[ ] Trauma [ ] Sinkop [ ] Sakit kepala [ ] Nyeri sinus [ ] Lain-lain

Mata
Mata
[ ] Tajam penglihatan [ ] Lapang pandang [ ] Penglihatan ganda [ ] Mata merah [ ] Sekret

[ ] Fotofobia [ ] Lakrimasi [ ] Trauma [ ] Rasa sakit [ ] Lain-lain

Telinga
Telinga
[ ] Ggn. keseimbangan [ ] Ggn. penghidu [ ] Gejala sumbatan [ ] Post nasal drip [ ] Sekret

[ ] Trauma [ ] Tinitus [ ] Nyeri [ ] Ggn. pendengaran [ ] Lain-lain

Hidung
Hidung
[ ] Nyeri [ ] Sekret [ ] Lain-lain

Mulut
[ ] Bibir [ ] Gusi [ ] Lidah [ ] Stomatitis [ ] Selaput lendir

[ ] Gigi-geligi [ ] Ggn. pengunyah [ ] Ggn. pengecap [ ] Sekresi ludah [ ] Bercak putih

[ ] Lain-lain

Tenggorokan
Tenggorokan
[ ] Nyeri menelan [ ] Batuk [ ] Sukar menelan [ ] Suara serak

Leher
Leher
[ ] Tiroid [ ] Adenitis [ ] Lain-lain

Jantung/Paru-paru
Jantung/Paru-paru
[ ] Nyeri dada [ ] Berdebar [ ] Edema (tempat) [ ] Sesak nafas

[ ] Ortopnea [ ] Sianosis [ ] Serangan asma [ ] Batuk

[ ] Keringat malam [ ] Batuk darah [ ] Lain-lain

Lambung/usus
Lambung/Usus
[ ] Rasa kembung [ ] Mual [ ] Muntah [ ] Mencret (frekuensi) [ ] Nyeri (sifatnya)

[ ] Sukar menelan [ ] Muntah darah [ ] Ikterus [ ] Wasir [ ] Tinja berdarah

[ ] Tinja warna dempul [ ] Tinja warna ter [ ] Lain-lain

Salurankemih/Alat
Saluran kemih/alat kelamin
kelamin
[ ] Disuria [ ] Stranguria [ ] Poliuria [ ] Polakisuria [ ] Kencing menetes

[ ] Kencing batu [ ] Kencing nanah [ ] Ngompol [ ] Inkontinensia [ ] Retensi

[ ] Hematuria [ ] Kolik ginjal [ ] Kolik ureter [ ] Oliguria [ ] Anuria

[ ] Penyakit prostat [ ] Lain-lain

Tuliskan catatan keluhan tambahan berupa tanda ( √ ) di samping judul yang bersangkutan.

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ANAMNESIS SISTEM (Sambungan)

Anamnesis Sistem (sambungan)

Katamenia
Katamenia
[ ] Menars [ ] Haid [ ] Teratur, lama [ ] Jumlah

[ ] Nyeri [ ] Sakit kepala [ ] Ganguan haid [ ] Haid terakhir

[ ] Leukorea [ ] Gejala klimakterium [ ] Perdarahan pasca [ ] Lain-lain

menopause

Saraf dan Otot

[ ] Anestesi [ ] Parestesi [ ] Lemah/lumpuh [ ] Kedutan [ ] Kejang
(tik, fasikulasi)
[ ] Pingsan [ ] Tidak sadar [ ] Pusing (vertigo) [ ] Afasia [ ] Ataksia

[ ] Gangguan bicara [ ] Sukar mengingat [ ] Amnesia [ ] Lain-lain

Berat badan
Berat badan (kg)
[ ] Berat badan sekarang [ ] Berat badan rata-rata [ ] Berat badan tertinggi
kg kg kg
[ ] Berat badan menurun (jangka waktu) [ ] Berat badan naik (jangka waktu) [ ] Lain-lain
....... kg dalam ........ (minggu/bulan/tahun) ...... kg dalam ........ (minggu/bulan/tahun)
Tuliskan catatan keluhan tambahan berupa tanda ( √ ) di samping judul yang bersangkutan.

Riwayat Hidup
RIWAYAT HIDUP

Riwayat Hidup
Riwayat Kelahiran
Riwayat kelahiran
Tempat lahir: Cara persalinan: Penolong persalinan:
Di rumah/Rumah Bersalin/Rumah Sakit Spontan/Khusus/Tidak diketahui Dokter/Bidan/Dukun/Lain-lain
Berat badan lahir (gram) *) Panjang badan lahir (cm) *) Lain-lain

Riwayat perkembangan
Riwayat perkembangan psikomotor*)
psikomotor*) (umur) (umur)
Miring Tengkurap Duduk Berdiri

Berjalan Bicara Membaca Lain-lain

RiwayatImmunisasi
Riwayat Imunisasi*) (umur)
*) (umur)
DPT BCG Campak Polio Lain-lain

Riwayatmakanan
Riwayat Makanan
ASI sampai umur *) Pengganti ASI, nama *) Makanan lain sewaktu bayi (diperinci) *)

Nafsu makan Gangguan pencernaan Makanan sekarang: (frekuensi/hari ; jumlah/kali ; variasi)

Sikap atauHubungan
Sikap atau Hubungan dengan
dengan
Ayah Ibu Saudara Pasangan (suami/istri) Lain-lain

Pendidikan
Pendidikan
[ ] SD [ ] SMP [ ] SMA [ ] Akademi [ ] Universitas [ ] Sekolah [ ] Kursus [ ] Tidak [ ] Lain-
kejuruan sekolah lain
Pekerjaan
Pekerjaan
Jenis Masa kerja Jam kerja Jarak rumah - tempat kerja Lain-lain
…………… jam/hari
Perumahan
Perumahan
Sendiri/Menyewa/Menumpang Luas rumah Jumlah orang yang tinggal Rasio kepadatan

Daerah/lingkungan Lain-lain

*) untuk pasien anak

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RIWAYAT HIDUP (Sambungan)

Riwayat Hidup (sambungan)

Perkawinan
Pernikahan
Lama pernikahan Jumlah pernikahan Jumlah anak Kontrasepsi Lain-lain

Riwayat Obstetri
G, P, A (Gravida, Partus, Abortus) Jenis partus Komplikasi kehamilan/persalinan Lain-lain

Perilaku
[ ] Olah raga [ ] Merokok [ ] Teh [ ] Kopi [ ] Alkohol
- Dulu Jumlah rokok/hari : ..... batang
- Sekarang Lama merokok : ..... tahun
Indeks Brinkman :
[ ] Rekreasi [ ] Jamu [ ] Obat lain [ ] Lain-lain

MasalahPsikososial
Masalah Psikososial
yang yang Mempengaruhi
Mempengaruhi KesehatanKesehatan
[ ] Keuangan [ ] Pekerjaan [ ] Keluarga

[ ] Kebiasaan berobat [ ] Lain-lain

Pemeriksaan Jasmani
PEMERIKSAAN JASMANI

PEMERIKSAAN JASMANI
Pemeriksaan Umum
Pemeriksaan Umum
Tekanan darah Nadi (frekuensi, isi, regularitas, equal) Suhu (sublingual/aksila/anal) Pernapasan (frekuensi, jenis)

Kesadaran Keadaan umum Keadaan sakit Tinggi badan (cm)

(Baik/Sedang/Buruk) (Tampak tidak sakit
/Sakit-ringan/sedang/berat)
Sianosis Dispneu Keadaan gizi Berat badan (kg)
(Baik/Sedang/Kurang/Buruk)
Bentuk badan Habitus Cara berjalan Lingkar kepala (cm)

Cara berbaring dan mobilitas Umur menurut taksiran (tahun) Lain-lain

Aspek kejiwaan (status mental)

Tinggi laku Alam perasaan Cara proses berpikir
- Wajar (Biasa/Sedih/Gembira/Cemas/Takut/ - Wajar
- Gelisah/tenang Marah) - Cepat/Lambat/Terhambat
- Hipo-aktif/hiper-aktif - Gangguan waham/Fobia/Obsesi
Kulit
Kulit
Warna Efloresensi Jaringan parut Pigmentasi

Keringat (umum/setempat) Turgor Ikterus Pertumbuhan rambut

Pembuluh darah Lapisan lemak Edema Suhu raba (lembab/kering)

Lain-lain

Kelenjar Getah
Kelenjar Getah Bening
Bening
Submandibula Leher Supraklavikula

Ketiak Lipat paha Lain-lain

Kepala
Kepala
Ekspresi wajah Simetri muka Deformitas Rambut

Pembuluh darah temporal Nyeri tekan (sinus) Noktah nyeri (saraf) Lain-lain
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PEMERIKSAAN JASMANI (Sambungan)

PEMERIKSAAN JASMANI (Sambungan)

Mata
Mata
Enoftalmus/Eksoftalmus Deformitas Gerakan Tekanan bola mata Kelopak

Konjungtiva Sklera Kornea Pupil (besar, refleks) Lensa

Visus tanpa koreksi Lapang pandang Lain-lain

Telinga
Telinga
Daun telinga: Retro aurikuler: Uji penala: Liang telinga:
[ ] Deformitas [ ] Tanda radang [ ] Rinne [ ] Tanda radang
[ ] Tanda radang [ ] Fistel [ ] Schwabach [ ] Serumen
[ ] Tofi [ ] Lain-lain [ ] Weber [ ] Sekret
[ ] Lain-lain [ ] Lain-lain [ ] Lain-lain

Gendang telinga Lain-lain

Hidung
Hidung
Bentuk luar (abses/trauma/deformitas) Vestibulum nasi

Lain-lain

Mulut dan tenggorokan

Bibir Selaput lendir mulut Faring Arkus faring

Tonsil Gigi-geligi Lidah Bau pernapasan

Lain-lain

Leher
Leher
Kelenjar gondok Trakea Tekanan vena jugularis

Kaku kuduk Lain-lain

Paru
Paru
Inspeksi

Palpasi

Perkusi

Auskultasi

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PEMERIKSAAN JASMANI (Sambungan)

PEMERIKSAAN JASMANI (Sambungan)

Jantung
Jantung
Inspeksi

Palpasi

Perkusi

Auskultasi

Pembuluh Darah
Pembuluh darah
A. temporalis A. karotis A. brakialis A. radialis

A. femoralis A. poplitea A. tibialis posterior A. dorsalis pedis

Lain-lain

Perut
Abdomen
Inspeksi

Palpasi

Hati

Limpa

Ginjal

Lain-lain

Perkusi

Auskultasi

Refleks kulit dinding abdomen

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PEMERIKSAAN JASMANI (Sambungan)

PEMERIKSAAN JASMANI (Sambungan)

Alat Kelamin
Alat Kelamin (atas
(atas indikasi)
indikasi)
Laki-laki Penis Skrotum Testis Lain-lain

Perempuan Genitalia eksterna Fluor albus Darah Lain-lain

Rambut Lain-lain

Anus dan Rektum

Anus dan Rektum Colok dubur (atas indikasi)

Punggung
Punggung
(Pasien dapat berdiri, duduk, atau telungkup. Mengenai hal-hal yang belum tercakup pada pemeriksaan-pemeriksaan sebelumnya.)
Inspeksi

Palpasi

Perkusi

Auskultasi

Nyeri ketok Gerakan

Lain-lain

Anggota Gerak
Anggota Gerak
Lengan Otot Gerakan Sendi Lain-lain
- Trofi
- Tonus
- Kekuatan
Tangan Warna Tremor Kuku Jari Lain-lain

Tungkai Luka Varises Parut Otot Sendi

dan kaki
Gerakan Kekuatan Edema Lain-lain

Refleks Tendon Biceps Tendon Triceps Tendon Achilles

Kulit kremaster Lain-lain

Sensibilitas Superfisial Dalam Lain-lain

Lain-lain

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Hasil Laboratorium Tulis tanggal dan waktu pemeriksaan!
Darah

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HASIL LABORATORIUM

HASIL LABORATORIUM
Tuliskan tanggal dan waktu pemeriksaan.
Darah

Urine

Urine

Tinja
Tinja

Lain-lain

Lain-lain

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RingkasanDATA
RINGKASAN Data Klinis
KLINIS
Narasi singkat berisi penemuan positif dari anamnesis, pemeriksaan jasmani dan laboratorium yang
menunjang untuk menetapkan masalah.
Anamnesis:
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Pemeriksaan Jasmani:
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Laboratorium:
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DaftarMASALAH
DAFTAR Masalah
(dapat berupa diagnosis, gejala, kelainan dan keadaan lain, berdasarkan konsep bio-psiko-sosial)
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Pengkajian
PENGKAJIAN
Analisis tiap masalah dan rencana penyelesaiannya.
Merupakan alasan memilih diagnosis berdasarkan penemuan dan pembahasan diagnosis banding. Gejala
atau kelainan yang dikeluarkan lagi dari diagnosis perlu diberi landasan penyebabnya.
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Rencana
RENCANA
Pemeriksaan
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Pengobatan
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Penyuluhan
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Kesimpulan
KESIMPULAN
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Prognosis
PROGNOSIS
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Buku-buku dan karangan yang berhubungan dengan kasus di atas yang Saudara baca:
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CATATAN PERKEMBANGAN
Nama Lengkap Pasien: No. Rekam Medis:

Tanggal Divisi Catatan Perkembangan

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 DAFTAR MASALAH

Nama Lengkap Pasien: No. Rekam Medis:

Tanggal No. Masalah Tanggal Masalah

Selesai

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