FACULTY OF

MEDICINE
I~u P H
!f,',...::-o::-c::

Student Record

L MEDICINE SHEET
LEMBAR KASUS PENYAKIT DALAM / INTERNA
Nomor Kasus Ca.,e Num ber.

ldeotitas Pasien / Patie11t lde11tity

Nrum Name : VJ tJUrfunoh

Kela min / Sc.r :~

Umu r I Age : c;c; tu\'lun

Status pcrkawinanl Marital Status : TO'U\11<.uh

Agam i i Religion : 1'>\UrO

No.Rekam Med is/Medical Record : ao · % · l-Y

Status Pembayaran / Payment : e,PSS

Statt,s

>-~ I c; 111
Tanggal masuk RS I Date ofAdmission
;1/C ,/l\
TanggaJ peireriksaan I Date ofExamination
nesis dari:
lnformasi dipcroleh secara autoanamnesis/ alloanam
sfrom:
Infon11ation gathered by autoanamnesis I alloa11am11esi

ca,r l(dui,:: 1 hun ~Mil~.

KeJuhan utama / Cltie/Co111plai11t: P;AS

Rbzess:
Riwayat Pcnyakit Seka ran g/ History ofPrese11t
e,As u11r <yo~ \ na..-i \Nil~ SAS tu1r \'\mgou
>;,.ox
,as,tll uaron9 1<e, H,o cJtriytt" \(.tJUt\U"
uili\ it ic.um1\ttJH i ~Ft~ \t.fVh o\r . 'oc,w
orno K°'--un,nyun . nao1<
1.1,"' pvut cJ•row<on Hft.m
I ~u 0.1 U(.\\.1(1 pup CJ\ JU~ 0
UtU\lpun t.lllruh • ompu~ 0 \JO\Uf 'I\{, IX ~PIV, 1.
OUCJ ltndir
JU90 mtl\9uttJ .... QI'\ atto nya Ut.m om ,
Clc.lOl'IIJ(J 1"1'\UQ\ ,OOIT\UI\ MOK l'Y'Ul\roh fU~I U\
Nlt.r'90t1.U(III\
p 0~11.rt N\tll\ J o"<,KU I u<Jan ~CJ n woy af
c.1 •Uku r
dtN\t1m .lUflltJIO • surocng numul'I Whunyc.a t'\CJtJk
on utuu <A t.mOl'I\ YUl\(J "l'U'llburu1<
puut1 hlOICJIY\ hem Pu~ l"t.n J uy o mu q o h.tKan ouun ~ <,
bq>t,91

t\ytn PO llU Uluh !lri R,1(1111r

nuol ' ,v,vni111<.1 mou_y11t 01u9 i m~.,v~,uru1<c,i, JUl't\luh "", t.

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pu11l.,r\ P"

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net
a~ OuQ nyU'l .. uaroh . tu·ou "Yt..n f>'"99<mg

l purp ou onlJ
ll&n) • unluk kebutub■n ~ndldik■n / For t'ducationa
STH 1403. 01/1
 Hospitals
Student Record

Riwayat Penyakit Dahulu / History ofPast Rl11ess:

Rhvayat sakit sebelumnya/ History ofpast illness
0
Rhvayat operasi / Histo,~• ofsurge,y
e)
Riwayat Pengobatan / Treatment History:
E>

Riwayat Kebiasaan / Habit:

mu-01<.ol(. 0
UIKOl'\ol 0
"1APU'i. c)
Riwayat Sosial Ekonomi / Social Economy Status
PU \ IV\ UU-0 b Cl I 09 SP J t

Riwayat Diet ( Pola makan) / Diet:

p,~,,U\ f1'11J.,.,Jn 1>< 1tk!Or\
\, MOOK t\..lon,r i~ lll< Ulorc.

Jtiwayat Pcnynkit Kclunrgn / Family II/story:

(Cia,mar genealogy)
t\Ubr. !JlJrJ V..uunoo \uupc. pu<.10 ktlUorgo

Haoya uotuk Jubutuhao ptodJdlk.a o / For educatlonal purpose only

STH 1403.01/ 1
 FACULTY OF
·Hospitq.ls MEDICINE

Student Record

Anamnesis Berdasarkan Sistem (Systematic Review)

~ Keluhan keadaan umum / General Complaint
Panas bad an / Fever 0
• Kapan mulai timbul / Since , hon <.M ~~
• Tipe Type 10w Qru ot. ft.II c..r
Nafsu makan / Appetite .i, 1hun \t-\11-~
Edema / Oedem 0
lkterus lcte111s 0
Haus/Thi,Jt 0 ,non <.M'-~
Bernt badan Body ueight 0

B. Kcluhan organ di kepala / Head Complaint

MJt.1 ,I!)-,• (:)
ll llung/ Nmc (:)
Lilah / 1o11g11,• 0
Cangguan m:nclan \1 ·,,/lull'i11g Dimrderr 6
Suk it kcpa la/ I lrmlac/1£ 0
re linga / Hm 0
M11l11t / M,mrli 0
C,1g1 / /'e<1th 0
Su:11 ,I / l'Olt'I! (:)

C. Kcluhun organ di lcher / Neck Co111plai11t

Kaku kuduk / Ned, \ t,ff,ie\.\ ()
Pcnbcsar.111 kclcnjar / L)mphnodesEnlargement 0

D. Kcluhan organ di thorax (n.~ pirasi dan kardiovaskuler) / Thorax Co111plai11t

Scsak nafa~ Breath/els 0
Sak it dada Che.st pam 0
Bat ul- Couy,h O
Jantung bL:rdcbar / Palpitation 0
Nafa.s bcrbunyi / "hee:ing (j

E. Keluban organ di perut / Abdo111ina/Co111plai11t

Nyeri / Pain 0
• Lokalisasi localization CJUI\Jh cu,oomU\
• Sifal nyen / T)-pe of Pain thh\1\
• Peajabran Spreading 0
• Yang m=micu dan meredakao / Trigger and alleviating factors 0
• Skala nyen / Pam Scale :=ti 1c,
• Waktu dao dlnSJ Tune and Duration 0
Mual / Nau.sea Ev
Muntab-muntah Vomtting 0
Obst.,asi / defecation problem 0

lfu)• u11tuk k.tbutahu pndldlka11 I F11r dMU:IJinw ,wpD>I cmlJ

5TH 1403.0Hl
 -

FACULTY OF AJl.e1:1·
~iJf-FhiilJ Hospitals MEDICINE \a,
~ , . . _ . . . . c.,,.,,

Student Record

Dlarca / Diarrhea ©
Perubohnn bontuk til'\lo / Faeces changes ©
Pcrubnhan dolnm hald / Menstruatlonchangese
Tcnc1mtodnnum / Tcm~smlada11um 0
Pel'\.lhHhnn oir 110nl / Urlnti chm,g~,v0

F. Keluhan darl tongon don knkl / ExtremlfJI Complaint

Kolulurn ro10 knku / St(/!nfJ,f,V0
Artro1l1i /Anhro,vl,v G
Frnktur / Fract11rc G
Nycrl tcknn / Tcndtwncss (:)
Luko/bckn11 lukn( Wo1111d I Scar) 0
Udorm, prctlbinl / Oednn, Prr Tibial 0
Oonrnm pcdi·1 / Dor.mm Pttdls 0
Rn111 lcmah / WC'ak11ev,· ©
Jalnn / Walking 0
Pcrasaan kcsomut.nn / Tingling ©

G. Keluhan laln-laln / Miscellaneous Complaint

Keluhan alat rnotorls / Motorlc compfa/111 0
Kcluhun kelcnjar Endokrin / Endocrine complaint G
I. I Jnit.l / Mc mt111atlo11
1

2. DL1bctes Mcllltus
3. Tirold / Thyroid
4. Keluhan kelenjar limfe I lymph nodes complaint

FIFE (feeling- Idea - Function Expectation)

Perasaan hati / Feeling l.U'IIO\
Ide Sakit / Idea ofSickness suuot\ -tu\'\u
Fung11 / Function -ti
l~k1pcktu1i / fapl'ctat/011 n.tl\but\

Haoya uotuk kebutuban pcndldlkan / For tducatlonQ/ purpos, only

STH 1 ◄03,01/1
 FACULTY OF
Hospitals MEDICINE

Student Record

PEMERIKSAAN FISIK/ Physical Examination

IKESAN UMUM / Ge11eral Appearance

Keadaan umum / Ge11erai State
Kesan sakit / Impression of pain : ns
Kesadaran / Consciousness 0,\
GCS:E 4 Ve, M'-
Gizi / Nutrient
Tinggi Bad an/ Height 1c;o cm
Bera t badan I Weight ~o kg

Keadaan sirkulasi / Circulation

Tekanan darah / Blood Pressure : 110{?>() mmHg
Nadi / Pulse : &o x/menit
Suhu / Temperature : %.u °C

Keadaan pernafasan / Respiratory

Frekuensi I Frequency : ,i x/menit
Corak pcrnafasan/ Type ofRespiration: rt91J\'tr
Bau nafas (fetor ex ore) : e

IPEMERIKSAAN KHUSUS / Speci.ficExami11ation

Kepala / Head
I. Tengkorak/ Skull : Mrrn1>H.fC1\i
(bcntuk/ shape)
2. Muka / Face : f\Of1'YH1f OS\{.~
3. Mata I Eye : \Ul\'l(tl\ t.yO ©
Palpcbra / Eye lids : c.OVl'IO -(-
Komea / Cornea : Jun,h +/ t
Pupil / Pupil : I~ C>KO< 3 ""1\ I JR\ l1'i
Sklcra / Sciera : '::,\ -{-
Konjungtiva / Conjunctiva : CA-{-
4. Tclinga / Ear
5. Hidung / Nose
pernapasan cuping h.idung / Nostril breathing: <:)
6. Bibir / Lips : m1"0~,s 0
7. G_igi dan gusi / Teeth and Gum: P"V tltiro hon 0
8. Lidah / Tongue : coot-c.u tol'\9uc. 0
9. Roogga mulut / Mouth : h1rU'U'l\11 0
J0. Rongga leher / Neck : "' ,puur11\ 0
- pharing/ Pharynx :
- tonsil/Tonsil : t\/T\
11 . Kelenjar parotis / Paroac Gland: ob"

Hanya untuk kebuh1han pendJdlkan / For educadonal purpose only

STD 1403.0Ul
 FACU LTY OF ~u PH
-=:-o
!!l' ::-~
Hospitals MED ICINE 1

Stude nt Record

Leber / Neck
- lnspeksi kelenjar tiroid / Thyroid Gland 0
Inspection Jugular Venous Pressu re (tekana n vena jugular is)
pu lsas i vc na I Vein Pu/sation c; ~ l. c.m
reflekshepatOJugular / hepato jugula r reflex e
- Palpasi kaku kuduk / Neck Stiffness f)
Palpation kelenjar tiroid I Thyroid Gland 0
kelenja r getah bening / Lymph Nodes: (:)
- lain-lain Massa / Mass e,

Ketia k / Axil/a : H.rnbuora" K<o~ 0

Peme riksaa n Thora x / Chest Exami11ati.on

Paru/ lung
fnspcksi I Inspection Ptn9U'l 'lb0l'\9 u" uouo \ 11'Y\tlYlS ntttu uon 411,omi~

Palpasi / PalpatK>n <.h'C\t (J(fUn ~,o" \ll'Y)"ttr\S . rrtm1n t\ ~"'M..trH

Pcrkus 1/ percuu ion \OMr ~tlUt'\Jh PUrt\

Auskuhasi I au\ctdtatio11 ~s th , ro •/-, Wh -I-

Cor I lleart
lnspcks1 / lmpect wn 10\.l) <.on.11} 0

Palpasi I Palpation , tl'\.I.S c.orchs (:)

Pcrius i I percuH·io11 b<.tt<1s jQl\l'lJl\,9 Ubl)

Auskultasi / auscul tation ~~l reg , murm ur0. 9u11op 0

Peme riksaa n Abdo men / Abdom inal Exa111i11atio11

lnspeksi Jmpect ion 1.:t.m'but\J ,muH u 0 . h .ur (;). torut mt<Ju1u0

P~asi Palpati on mUHO 0 . . .n 0 ,nt.f0t't >r<l'tYO h 0 -~~\U\0l'C\t9CJ\I 0

Periru.si / percu,;sion ""'t>Ut\i ~ouruh lib ti O"OU\

Auskultasi auscul tation au G)

Han)'• uoluk kcbutuh ao pcodJdlk ao / For educa1ional purpo1e onlJ

STH 1•0J.0I/ J
 FACULTY OF A'».UPH
Hospitals
----~
MEDICINE \a, _..,.,._

Student Record

Kaki dan tangan / Extremities u1<ro1 Mn9u~ , CRT< l! , t.Utmo -/ -

Status Lokalis / Local Status:

Hu~• uotuk krbuluh•o peodJdlun / For eductrllonlllpurpou~ on/1

ffif J40J.OIIJ
 r.L.~
~it•tihi? Hospitals FACULTY OF
MEDICINE

Student Record

PEMERIKSAAN PENUNJANG / LABOR ATORI UM / Laboratory

Tanggal / Dau!
l.9/t,
Danh / Hematology
Hb / Hmioglobm
\~,~
Ld.O) ll I Lt!UkOC)1e Count
II Ol
Entros11 / Erythrocyte Count
c;, l
HIIUD&JClllS Dijfermtial Le11kOC) le C:011111
\-\\ ltl,l
• basophil / basopMle
0
• co~inolil I eosinop/11/
•
•
batang/ bond
scgmcn / segmented
,
I

1i
• hmfosit I lymphoc)1~
14
• monosu / monoc,1e
\.I
T rombo,11 'Tltroo,boc)·te
c;()2
LEO £:SR
\0
KJmla Oarah / Chcn1try
ckf~ 9\
Urcum
l'b
Krca1mmc Crcatmmc
O.lQ
!,C,O r
l~
~WI
l.1)
Sa ,,1o
K
Cl
4
vuJa d.vah puasa I Farnng Blood Sugar
99
Gula d.nh •~aktu Random Dlood SuK,tr
ql-
(1ula dMllh 2 Jim rr 11 houri p<1Hprund1al hlood ~11gor
Y,(llo,tcrol C./10/wuol
IIUL
LIJL
MW
MLH
~UH, 3\1, \
i,~
~l,l

Tngl1\Cl'W I TrtR/.ltt'Tult
M ■II a B ■ ab fU.tl
pH uJUrf'\U .
p02 'i<J>M\\N\~i
p1..ui uUJ\
I'll ..:
HC03 aorah -
l:Jt
a-AD02
l.rine
omc.c..b11
tQQ u>Grm
l.\tUl\
I.,
•l

•J
\\arm Colar 011\1\Uft\ j.J
Reaks1 xma,on
K.cmuhan Turbu/Jr)
FU\ -
f\bu-1
8&1 Odor O(.(.U I I- blOOt.l '~
"
A.lbumm
Rcduks1 kdua,on
l,robtlm
Bihrubm
ScdJ mcn S edurr tnt
EnmK11 £rythrocru 0-1
Lckolla Ln.kOClU ,-;
Kruul Cntt.JI

H■ D}I uotuk kebutuhao pendldlkan I For educational purpost on/)

STH 1403.01/1
 FACULTY OF
Hospitals MEDICI NE

Student Record I,,

I'"·· _••Li
1111111111111

EKG/EC G
111\1.H r h~H11n G1 11"\\ O,H
H Q. \0(/X /m I' ~ IT'fO\ 0
Pk 11\l'vVOI o,8 ~
Gt~ <.om plt,X o,o'i>~
H t.(OJCHi 0 <l -q>ru, 0
G fOtotooit 0
Ml m(I UX .}
Pencitra an / Jmagi.11g
v.o. ll.4/c,(1..)
4 io!..Qr01c.mc9011 1J9 CA11n9 oii aortu

MV. UbtJ~II\U\ ll.lj/C:,/l1)

\.j t\WI Clblt"ru~JI 0
utJOrfJ t>tA!os 0
!J)l:, Wher1t. U'c,U(lfTIU\

~ fO\f'Y \IVV

orgun ubtlomV\ Hunn~a Ubf\

Hu) 1 unluk krbu1uhan prodldlliuln / For ~ducaJional purpou only

STH J403.0 lit
 FACULTY OF

E.1@luft Hospitals MEDICINE

Student Record

IIKHTISAR / Summary

IDAFTAR MASALAI I / List ofProblem

Manya UAtuk kebuluban prndldlk.an / For ,ducatlo11al purpo1• only

STH 1403.01/1
 ~uPH
Student Record
Hospitals FACULTY OF
G---~
MEDICINE \a,_,.,,._

IPENGKAJIAN / Assessment
Q) ~A 1h.n901\ Oth,cJ ro1 i nngun JWang
((i"/ci]. c.tl\CJl1\I\Ui~ watvy dlorrhto • \'U'ooir0 · unnt OU\-?\At ~

· r.y W (>U\H Hft.rti llililit · flOUl@

· muul © muMoh 0
• IO\JJ 9nJU~ f~
Pf : N\Ut'(J C,'(J<.Ur\g 't/ \
uo ~
~1<.1" rurg or 1c,m1>01

Vt.J\\JnJUI\_IJ : NU l'>C.,. K 4 , (J. 99

fur,IK\tKOI\ \ <oE~ \U'f (..(, bUKt'Ui \<UrtA\U IC.UU\'\(Jf\ <11scrnf1 uunom yon9 nuak \<11\(JJUl\(J

lol r(ll'I

~ ~ l.c; KU\ I ~P> I hCJ.n

"ru.u w1run.. 4 IC.GO

frihl uKtw,n,\ nn9on , 01\trrs.s ➔ \«;c;o \ \41o<; :: 1.015 ~ol

OClt1,nuJ1~UMV\IV\ 0 U.l. ~ \ \<o lor,

· turgt,t <l•UM(\ o,c,m, /\c.9t>e>/hour

• OIJIIJ'lc.,.(. l1Jlrt11'\ \ t °4100 (A,./hun)

-01 tJ(, ~IPl1\

• O~\ Vile pt,I~

- ri\tif\lttr nmua IJO'\tO rusi

· tau. o,gc/, \(IMlJV-gP,~tLJUfT\)

- car-rupu19 •1 ii;orn_g nop S~'?, tu, r

Huya untuk kebutuhan pe-odJdlk.u / For t!d11cllllonalpurpo,r onlJ

sm 141JJ.0111
 Hospitals FACULTY OF
MEDICINE \a, _ __
Ka.UPH-
O_ P__.,. Oloblla-.

Student Record

IPEMETAAN MASALAH /Problems Mapping

lJU1l'YO't.(\ tri h!

\f\ftl\ l 10'/,} \i11u-t.nu ( (O·lo '/o) oltitr ( <I0'/0)

l /
paH,09c.n,c. 1flfi\ hutlo" of
,cntro,n tt1nno1 trCJ u
~ j \ ~MUlCJJ/,Om,\

~OthlXjtfl tl)~\ll~
~utno9U\1 c. t
ll\\"uathOI\ "'' 11\t'U Uhoo Of
H"\l'I\U\Ult t.tulc.
otJVoui ry<IUI\ brush 'oordu-
(1 JCC.IU\0(\
~ o.UilAty

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it)~\01101\ Of
~
V\H UlJ\ f\VV'(,
OFf UU'I\
"\ Cg\ f I lllll ~C.Lt'U10f\ ~
mu\Q'o\Orfll'\Ofl

~
at:iueim1no1
p<m\
.i
(1\Urt,
i wutu
l <.opouhj

HID) a untuk ktbutuban ptndldlkan I For eduCJUlonaJ purpo•• on/1•

STU J•OJ.01/1
 FACULTY OF
,iit•Eh1h~ Hospitals MEDICINE

Student Record

IPROGNOSIS / Prog11osis
04 \lltOm • \IU'.)\U OU ioC>I\Ul'n

Q(! f Uf\<.\'\01\ om · c\\J'o\ U UU b Of\011)

a c.l rnno honam : dull IC.1 Q c.t bo!'lon')

IDJSKUSI / Disc11ssio11

Haoy• unluk l.cbutuban pl'ndldlklln / For l'ducllllonal purp<,tl' only

STH J-403.01/1
 •
~uPH
l-iif•Ei,1i~
Student Record
.Hospitals FACULTYOF
MEDICINE \a, _ _ _
--~~
IF ollow up

~ama dan ttd mahasls,,a/Student 's name and signature

( llt Stl>./un t,Sf-rD )

Hanya uncok lubuluhan p, ndldlbn / For tducllllonlll purpou o,rl)I

m a1,01.0111