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 :

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Keadaan Gizi :

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Kesadaran :..................................................

Pernafasan :.....................................

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Suhu : ..........................

Tekanan Darah :

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.........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

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Paru :...............................................................

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Perut :..........................................................................................................................

Hati :..........................................................................................................................

Limpa :..........................................................................................................................

Ginjal :..........................................................................................................................

Kandung empedu :

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.............................................................................................Kandung

kencing :.............................................

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................Kemaluan

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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