status ujian bedah
Post on 19-Jan-2016
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Mata Ujian : ILMU BEDAHHari / Tanggal Ujian : .................................................
Rumah Sakit Margono Soekarjo
Nama Mahasiswa
: ..............................................................................
N.I.M.: ..............................................................................
N.I.R.M.: ..............................................................................
IDENTITAS PASIEN
Nama : _____________________________________Jenis Kelamin
: _________________
Umur : _____________________________________ Bangsa : _________________Pekerjaan
: _____________________________________ Agama : _________________
Alamat : _____________________________________
I. ANAMNESISDiambil dari :
_________________________________Tanggal : ..........................
Jam : ...................
1. Keluhan Utama :
2. Keluhan Tambahan :
3. Riwayat Penyakit :
4. Riwayat Keluarga :
5. Riwayat Masa Lampau
1). Penyakit Terdahulu : _____________________________________________________________
2). Trauma Terdahulu : _____________________________________________________________
3). Operasi : _____________________________________________________________
4). Sistem Saraf : _____________________________________________________________5). Sistem Kardiovaskuler
:_____________________________________________________________
6). Sistem Gastrointestinal :
_____________________________________________________________
7). Sistem Urinarius : _____________________________________________________________
8). Sistem Genitalis : _____________________________________________________________9). Sistem
Muskuloskeletal :_____________________________________________________________
10). Sistem Respiratorius :
_____________________________________________________________
II. STATUS PRAESENS
1. STATUS UMUMKeadaan umum :
..................................................
Keadaan Gizi :
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Kesadaran :..................................................
Pernafasan :.....................................
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Suhu : ..........................
Tekanan Darah :
..........................
.........Nadi :
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Kulit :.............................................................
Kelenjar limfe :
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Muka :.............................................................
Kepala :...........................................................
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Mata :.............................................................
Telinga :
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Hidung :.............................................................
Mulut / gigi :
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Leher :.............................................................
Dada :
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.................Jantung
:.............................................................
Paru :...............................................................
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Perut :..........................................................................................................................
Hati :..........................................................................................................................
Limpa :..........................................................................................................................
Ginjal :..........................................................................................................................
Kandung empedu :
.................................
.............................................................................................Kandung
kencing :.............................................
.............................................
................Kemaluan
:..........................................................
Rectum / Anus :
...................................
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Punggung :
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...............Ekstremitas :
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Refleks :.............................................................
Sensibilitas :
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2. STATUS LOKALIS
III. PEMERIKSAAN KHUSUS LAIN
IV. LABORATORIUM
V.RESUME
VI. DIAGNOSIS KERJA
VII. DIAGNOSIS BANDING
VIII. PEMERIKSAAN ANJURAN
IX. PENGOBATAN
X. PROGNOSIS
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