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INTERNA

STANDAR KOMPETENSI DOKTER

INDONESIA (SKDI)

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#1:

KARDIOVASKULAR

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1. NAMA PENYAKIT

STEP : ANAMNESIS PF JANTUNG PP (APA?) TERAPI EDUKASI

(step ini hanya contoh saja, karna tiap penyakit mungkin punya

step yang berbeda-beda)

NO CHECK LIST KETERANGAN1 MEMBUKA WAWANCARA

Assalamualaikum wr wb sa!a"$%a$ "&k'r Ar'ri&

ANAMNESIS IDENTITAS

1 Nama Usia

* Alama'+ Pkr,aa$

*RIWAYAT PENYAKITSEKARANGA"a klu-a$ a.a !a$% iburasaka$/

+ L&kasi1 Saki'$!a "isbla- ma$a

!a bu/0 O$s' "a$ kr&$&l&%i

1 S,ak ka.a$ rasa .usi$%

"irasaka$/ A.aka- rasa saki' mu$ul

'rus m$rus a'au-ila$% 'imbul/

* 2iasa$!a ka.a$ 'rasasaki'/ Saa' ak'i3i'as4saa'is'ira-a'/

+ Dskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$-arus "i'a$!aka$

5laska$ ,awaba$6,awaba$ !a$%m$%ara- k .$!aki' !a$% i$%i$

"i"ia%$&sis .&i$' .$'i$% a.a !a$%mru.aka$ .r'a$"a a'au kri'ria"ia%$&sis "ari sua'u .$!aki'

7 Kuali'as klu-a$1 Pusi$%$!a s.r'i a.a/

S.r'i "i'usuk6'usuka'au 8

A.aka- .usi$% "isr'ai$!ri s$"i bla bla

* A.aka- .usi$%$!a sam.aim$%%a$%%u ak''i3i'as/


5laska$ ,awaba$6,awaba$ !a$%m$%ara- k .$!aki' !a$% i$%i$"i"ia%$&sis .&i$' .$'i$% a.a !a$%mru.aka$ .r'a$"a a'au kri'ria"ia%$&sis "ari sua'u .$!aki'

9 Kua$'i'as klu-a$1 Sbra.a sri$%

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.usi$%$!a mu$ul/ Dskri.sika$ .r'a$!aa$

lai$$!a !a$% mu$%ki$-arus "i'a$!aka$

;ak'&r mm.rbra'

1 Pusi$%$!a 'amba- saki'kalau a.a/

Dskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$-arus "i'a$!aka$

< ;ak'&r mm.ri$%a$1 S'ia. .usi$% a.a !a$%

ibu lakuka$ su.a!a lbi-$aka$/

Dskri.sika$ .r'a$!aa$

lai$$!a !a$% mu$%ki$-arus "i'a$!aka$1= Klu-a$ lai$

1 MUNTA>

A.aka- ibu mrasaka$mual "a$ mu$'a- saa's"a$% .usi$%/



11

RIWAYAT PENYAKIT DAHULU

1 A.aka- ibu .r$a-m$%alami saki'4%,alas.r' i$i

A.aka- ibu a"a riwa!a'"ll !a$% br-ubu$%a$"$%a$ .$!aki' !a$%"i"ri'a

P&i$' i$i u$'uk m$'uka$ DD ?ak'&r

rsik& .$!aki' !a$% "i"ri'a

1RIWAYAT PENYAKITKELUARGA

1 A.aka- kluar%a ibu a"a

!a$% m$"ri'a saki's.r'i i$i/ Dskri.sika$ .r'a$!aa$


1*RIWAYAT LINGKUNGANSOSIALDskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$ -arus"i'a$!aka$

1+ Kbiasaa$ .riba"i .asi$

1 A.aka- ba.ak sri$%m$%k&$sumsi blab la

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A.aka- ba.ak mr&k&k/PEMERIKSAAN TANDA VITAL

5ika "i.rluka$ .@ 'a$"a 3i'al maka lam.irka$ klis' .mriksaa$ 'a$"a 3i'alPEMERIKSAAN FISIK JANTUNG

(li-a' klis .? kar"i&3askular)

'ulis .mriksaa$ sik !a$% -arus "ilakuka$ ssuai "$%a$ .$!aki' lam.irka$klis' .? .a"a -alama$ 'rak-irPEMERIKSAAN PENUNJANG

'uliska$ .mriksaa$ .$u$,a$% !a$% -arus "ilakuka$ u$'uk m$"uku$%"ia%$&sis

sr'aka$ -asil .. !a$% mu$%ki$ 'r,a"i ,u%a b&l- "alam b$'uk lam.ira$ ,ika'rlalu ba$!ak

10 PEMERIKSAAN GULA DARAH Ka"ar $&rmal bla bla

DIAGNOSIS BANDING

17 DD:1 >i.r'$si B.-al%ia* Kuma-a+ Dama$%

PENATALAKSANAAN17 RESEP OBAT

Tuliska$ rs. &ba' !a$% b$ar"a$ l$%ka. ssuai "$%a$'ra.i !a$% "ia$,urka$B&$'&- :

R4 >i"r&-l&r&'iaCi" 'ab m%10 S 1 "" 'ab 1

5ika .rlu 'uliska$ rs. br"asarka$ li$ia'au %ra" .$!aki' !a$% mu$%ki$"i"ri'a

19 EDUKASI

Ti"ak b&l- mr&k&k

Tuliska$ "ukasi !a$% -arus"ibrika$ k.a"a .asi$

PENUTUP2ri ksim.ula$ m$%$ai

.$!aki' !a$% "i"ri'a .asi$m$u'u. .ra.aka$ "$%a$salam

See!"# $%$ &$'" $"&"#*"% +e%,e!"'"% e%-e%"$ +e%"*$e/'e&0 'e+e/$ -e,"!" "2/ $%2/ #"'$! +3.!"& -/"$%-

+e%"*$ -"&"/"% e*- -"&"/"% 422 #2/"3 "%#"'$!%" +ee/$*'""% +e%0%,"%- - !e&$# e"$! "% #"!

!"$% $/"'" +e%$%- 0%0* $*e"#0$ 0%0* e%e-"*"%$"-%2'$' "!-2/$" !"%-*"# e/"+$. U%0* "'$%-5 &"-$"%&$'" ,0-" e%e/"*"% !"+$/"% 6e*!$' +ee/$*'""% #2/"3,"%0%- "&2e% 7 !! "%- e%0*0%- '0& &"& $%e/%"

+2*2*%"

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SERTAKAN SLEENGKAP MUNGKIN YAAW

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#:RESPIRASI

1. NAMA PENYAKIT

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(step ini hanya contoh saja, karna tiap penyakit mungkin punyastep yang berbeda-beda)



ANAMNESIS IDENTITAS

0 Nama7 Usia9 Alama' Pkr,aa$

* RIWAYAT PENYAKITSEKARANGA"a klu-a$ a.a !a$% iburasaka$/

+ L&kasi Saki'$!a "isbla- ma$a

!a bu/0 O$s' "a$ kr&$&l&%i

0 S,ak ka.a$ rasa .usi$%"irasaka$/

7 A.aka- rasa saki' mu$ul

'rus m$rus a'au-ila$% 'imbul/

9 2iasa$!a ka.a$ 'rasasaki'/ Saa' ak'i3i'as4saa'is'ira-a'/


5laska$ ,awaba$6,awaba$ !a$%m$%ara- k .$!aki' !a$% i$%i$"i"ia%$&sis .&i$' .$'i$% a.a !a$%mru.aka$ .r'a$"a a'au kri'ria

"ia%$&sis "ari sua'u .$!aki'

7 Kuali'as klu-a$0 Pusi$%$!a s.r'i a.a/

S.r'i "i'usuk6'usuka'au 8

7 A.aka- .usi$% "isr'ai$!ri s$"i bla bla

9 A.aka- .usi$%$!a sam.aim$%%a$%%u ak''i3i'as/



9 Kua$'i'as klu-a$* Sbra.a sri$%

.usi$%$!a mu$ul/+ Dskri.sika$ .r'a$!aa$

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;ak'&r mm.rbra'* Pusi$%$!a 'amba- saki'

kalau a.a/


< ;ak'&r mm.ri$%a$* S'ia. .usi$% a.a !a$%

ibu lakuka$ su.a!a lbi-$aka$/


1= Klu-a$ lai$ MUNTA>




11RIWAYAT PENYAKIT DAHULU

* A.aka- ibu .r$a-m$%alami saki'4%,ala

s.r' i$i+ A.aka- ibu a"a riwa!a'

"ll !a$% br-ubu$%a$"$%a$ .$!aki' !a$%"i"ri'a

P&i$' i$i u$'uk m$'uka$ DD ?ak'&rrsik& .$!aki' !a$% "i"ri'a


* A.aka- kluar%a ibu a"a!a$% m$"ri'a saki's.r'i i$i/


1*RIWAYAT LINGKUNGANSOSIALDskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$ -arus"i'a$!aka$

1+ Kbiasaa$ .riba"i .asi$* A.aka- ba.ak sri$%

m$%k&$sumsi blab la

+ A.aka- ba.ak mr&k&k/PEMERIKSAAN TANDA VITAL

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5ika "i.rluka$ .@ 'a$"a 3i'al maka lam.irka$ klis' .mriksaa$ 'a$"a 3i'alPEMERIKSAAN FISIK JANTUNG

(li-a' klis .? kar"i&3askular)'ulis .mriksaa$ sik !a$% -arus "ilakuka$ ssuai "$%a$ .$!aki' lam.irka$

klis' .? .a"a -alama$ 'rak-ir

PEMERIKSAAN PENUNJANG'uliska$ .mriksaa$ .$u$,a$% !a$% -arus "ilakuka$ u$'uk m$"uku$%

"ia%$&sissr'aka$ -asil .. !a$% mu$%ki$ 'r,a"i ,u%a b&l- "alam b$'uk lam.ira$ ,ika

'rlalu ba$!ak10 PEMERIKSAAN GULA DARAH Ka"ar $&rmal bla bla

DIAGNOSIS BANDING17 DD:

0 >i.r'$si

7 B.-al%ia9 Kuma-a Dama$%


Tuliska$ rs. &ba' !a$% b$ar"a$ l$%ka. ssuai "$%a$'ra.i !a$% "ia$,urka$B&$'&- :R4 >i"r&-l&r&'iaCi" 'ab m%10

S 1 "" 'ab 1


19 EDUKASI

Ti"ak b&l- mr&k&k


PENUTUP2ri ksim.ula$ m$%$ai.$!aki' !a$% "i"ri'a .asi$m$u'u. .ra.aka$ "$%a$

salam

See!"# $%$ &$'" $"&"#*"% +e%,e!"'"% e%-e%"$ +e%"*$e/'e&0 'e+e/$ -e,"!" "2/ $%2/ #"'$! +3.!"& -/"$%-

+e%"*$ -"&"/"% e*- -"&"/"% 422 #2/"3 "%#"'$!%" +ee/$*'""% +e%0%,"%- - !e&$# e"$! "% #"!

!"$% $/"'" +e%$%- 0%0* $*e"#0$ 0%0* e%e-"*"%$"-%2'$' "!-2/$" !"%-*"# e/"+$. U%0* "'$%-5 &"-$"%&$'" ,0-" e%e/"*"% !"+$/"% 6e*!$' +ee/$*'""% #2/"3,"%0%- "&2e% 7 !! "%- e%0*0%- '0& &"& $%e/%"

+2*2*%"SERTAKAN SLEENGKAP MUNGKIN YAAW

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#*:ASTROINTESTINAL

>EPATO2ILIERPANKREAS

1. NAMA PENYAKIT

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ANAMNESIS IDENTITAS

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.usi$%$!a mu$ul/7 Dskri.sika$ .r'a$!aa$

lai$$!a !a$% mu$%ki$

-arus "i'a$!aka$ ;ak'&r mm.rbra'


7 Dskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$-arus "i'a$!aka$


ibu lakuka$ su.a!a lbi-

$aka$/7 Dskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$-arus "i'a$!aka$

1= Klu-a$ lai$* MUNTA>


Dskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$

-arus "i'a$!aka$



7 A.aka- ibu a"a riwa!a'"ll !a$% br-ubu$%a$"$%a$ .$!aki' !a$%"i"ri'a


1

RIWAYAT PENYAKIT

KELUARGA0 A.aka- kluar%a ibu a"a!a$% m$"ri'a saki's.r'i i$i/

7 Dskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$-arus "i'a$!aka$

1*RIWAYAT LINGKUNGANSOSIALDskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$ -arus

"i'a$!aka$1+ Kbiasaa$ .riba"i .asi$

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7 A.aka- ba.ak mr&k&k/PEMERIKSAAN TANDA VITAL

5ika "i.rluka$ .@ 'a$"a 3i'al maka lam.irka$ klis' .mriksaa$ 'a$"a 3i'al

PEMERIKSAAN FISIK JANTUNG(li-a' klis .? kar"i&3askular)






i.r'$si1= B.-al%ia11 Kuma-a1 Dama$%


Tuliska$ rs. &ba' !a$% b$ar"a$ l$%ka. ssuai "$%a$

'ra.i !a$% "ia$,urka$B&$'&- :R4 >i"r&-l&r&'iaCi" 'ab m%10 S 1 "" 'ab 1


19 EDUKASI

Ti"ak b&l- mr&k&k


PENUTUP2ri ksim.ula$ m$%$ai.$!aki' !a$% "i"ri'a .asi$m$u'u. .ra.aka$ "$%a$salam

See!"# $%$ &$'" $"&"#*"% +e%,e!"'"% e%-e%"$ +e%"*$e/'e&0 'e+e/$ -e,"!" "2/ $%2/ #"'$! +3.!"& -/"$%-

+e%"*$ -"&"/"% e*- -"&"/"% 422 #2/"3 "%#"'$!%" +ee/$*'""% +e%0%,"%- - !e&$# e"$! "% #"!

!"$% $/"'" +e%$%- 0%0* $*e"#0$ 0%0* e%e-"*"%$"-%2'$' "!-2/$" !"%-*"# e/"+$. U%0* "'$%-5 &"-$"%&$'" ,0-" e%e/"*"% !"+$/"% 6e*!$' +ee/$*'""% #2/"3

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,"%0%- "&2e% 7 !! "%- e%0*0%- '0& &"& $%e/%"+2*2*%"


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#+:

IN5ALSALURAN

KEMI>

1. NAMA PENYAKIT

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ANAMNESIS IDENTITAS

1* Nama1+ Usia10 Alama'17 Pkr,aa$

* RIWAYAT PENYAKITSEKARANGA"a klu-a$ a.a !a$% iburasaka$/

+ L&kasi+ Saki'$!a "isbla- ma$a

!a bu/0 O$s' "a$ kr&$&l&%i

1* S,ak ka.a$ rasa.usi$%"irasaka$/

1+ A.aka- rasa saki'

mu$ul 'rus m$rusa'au -ila$% 'imbul/

10 2iasa$!a ka.a$'rasa saki'/ Saa'ak'i3i'as4saa' is'ira-a'/

17 Dskri.sika$.r'a$!aa$ lai$$!a !a$%mu$%ki$ -arus"i'a$!aka$

5laska$ ,awaba$6,awaba$ !a$%m$%ara- k .$!aki' !a$% i$%i$"i"ia%$&sis .&i$' .$'i$% a.a !a$%mru.aka$ .r'a$"a a'au kri'ria

"ia%$&sis "ari sua'u .$!aki'

7 Kuali'as klu-a$1* Pusi$%$!a s.r'i

a.a/ S.r'i "i'usuk6'usuk a'au 8

1+ A.aka- .usi$%"isr'ai $!ri s$"i blabla

10 A.aka- .usi$%$!asam.ai m$%%a$%%uak''i3i'as/

17 Dskri.sika$.r'a$!aa$ lai$$!a !a$%

mu$%ki$ -arus"i'a$!aka$


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.usi$%$!a mu$ul/ Dskri.sika$ .r'a$!aa$

lai$$!a !a$% mu$%ki$

-arus "i'a$!aka$ ;ak'&r mm.rbra'




ibu lakuka$ su.a!a lbi-

$aka$/ Dskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$-arus "i'a$!aka$

1= Klu-a$ lai$+ MUNTA>


Dskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$

-arus "i'a$!aka$



A.aka- ibu a"a riwa!a'"ll !a$% br-ubu$%a$"$%a$ .$!aki' !a$%"i"ri'a


1

RIWAYAT PENYAKIT

KELUARGA9 A.aka- kluar%a ibu a"a!a$% m$"ri'a saki's.r'i i$i/


1*RIWAYAT LINGKUNGANSOSIALDskri.sika$ .r'a$!aa$lai$$!a !a$% mu$%ki$ -arus

"i'a$!aka$1+ Kbiasaa$ .riba"i .asi$

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A.aka- ba.ak mr&k&k/PEMERIKSAAN TANDA VITAL

5ika "i.rluka$ .@ 'a$"a 3i'al maka lam.irka$ klis' .mriksaa$ 'a$"a 3i'al

PEMERIKSAAN FISIK JANTUNG(li-a' klis .? kar"i&3askular)






1* >i.r'$si1+ B.-al%ia10 Kuma-a17 Dama$%





19 EDUKASI

Ti"ak b&l- mr&k&k



See!"# $%$ &$'" $"&"#*"% +e%,e!"'"% e%-e%"$ +e%"*$e/'e&0 'e+e/$ -e,"!" "2/ $%2/ #"'$! +3.!"& -/"$%-

+e%"*$ -"&"/"% e*- -"&"/"% 422 #2/"3 "%#"'$!%" +ee/$*'""% +e%0%,"%- - !e&$# e"$! "% #"!

!"$% $/"'" +e%$%- 0%0* $*e"#0$ 0%0* e%e-"*"%$"-%2'$' "!-2/$" !"%-*"# e/"+$. U%0* "'$%-5 &"-$"%&$'" ,0-" e%e/"*"% !"+$/"% 6e*!$' +ee/$*'""% #2/"3

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,"%0%- "&2e% 7 !! "%- e%0*0%- '0& &"& $%e/%"+2*2*%"


#0:

ENDOKRIN

META2OLIK

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NUTRISI

1. NAMA PENYAKIT


(step ini hanya contoh saja, karna tiap penyakit mungkin punya




ANAMNESIS IDENTITAS

19 Nama1 Usia1

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1

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s"a$% .usi$%/


11

RIWAYAT PENYAKIT DAHULU

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= Dama$%PENATALAKSANAAN

17 RESEP OBATTuliska$ rs. &ba' !a$% b$ar"a$ l$%ka. ssuai "$%a$



19 EDUKASI

Ti"ak b&l- mr&k&k



See!"# $%$ &$'" $"&"#*"% +e%,e!"'"% e%-e%"$ +e%"*$e/'e&0 'e+e/$ -e,"!" "2/ $%2/ #"'$! +3.!"& -/"$%-

+e%"*$ -"&"/"% e*- -"&"/"% 422 #2/"3 "%#"'$!%" +ee/$*'""% +e%0%,"%- - !e&$# e"$! "% #"!

!"$% $/"'" +e%$%- 0%0* $*e"#0$ 0%0* e%e-"*"%$"-%2'$' "!-2/$" !"%-*"# e/"+$. U%0* "'$%-5 &"-$"%&$'" ,0-" e%e/"*"% !"+$/"% 6e*!$' +ee/$*'""% #2/"3,"%0%- "&2e% 7 !! "%- e%0*0%- '0& &"& $%e/%"


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#7:

>EMATOLOIIMUNOLOI

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1. NAMA PENYAKIT

STEP : ANAMNESIS PF JANTUNG PP (APA?) TERAPI

EDUKASI(step ini hanya contoh saja, karna tiap penyakit mungkin punya




ANAMNESIS IDENTITAS

1 Nama Usia* Alama'+ Pkr,aa$

*RIWAYAT PENYAKITSEKARANGA"a klu-a$ a.a !a$% iburasaka$/

+ L&kasi7 Saki'$!a "isbla- ma$a

!a bu/

0 O$s' "a$ kr&$&l&%i1 S,ak ka.a$ rasa

.usi$%"irasaka$/ A.aka- rasa saki'


* 2iasa$!a ka.a$'rasa saki'/ Saa'ak'i3i'as4saa' is'ira-a'/

+ Dskri.sika$.r'a$!aa$ lai$$!a !a$%mu$%ki$ -arus"i'a$!aka$


7 Kuali'as klu-a$1 Pusi$%$!a s.r'i

a.a/ S.r'i "i'usuk6'usuk a'au 8

A.aka- .usi$%"isr'ai $!ri s$"i blabla

* A.aka- .usi$%$!a

sam.ai m$%%a$%%uak''i3i'as/


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+ Dskri.sika$.r'a$!aa$ lai$$!a !a$%mu$%ki$ -arus"i'a$!aka$

9 Kua$'i'as klu-a$

11 Sbra.a sri$%.usi$%$!a mu$ul/


;ak'&r mm.rbra'11 Pusi$%$!a 'amba-

saki' kalau a.a/1 Dskri.sika$

.r'a$!aa$ lai$$!a !a$%mu$%ki$ -arus"i'a$!aka$

< ;ak'&r mm.ri$%a$11 S'ia. .usi$% a.a

!a$% ibu lakuka$ su.a!albi- $aka$/


1= Klu-a$ lai$7 MUNTA>





11 A.aka- ibu .r$a-

m$%alami saki'4%,alas.r' i$i1 A.aka- ibu a"a

riwa!a' "ll !a$%br-ubu$%a$ "$%a$.$!aki' !a$% "i"ri'a



11 A.aka- kluar%a ibua"a !a$% m$"ri'a saki's.r'i i$i/

1 Dskri.sika$.r'a$!aa$ lai$$!a !a$%

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mu$%ki$ -arus"i'a$!aka$

1*RIWAYAT LINGKUNGANSOSIALDskri.sika$ .r'a$!aa$

lai$$!a !a$% mu$%ki$ -arus"i'a$!aka$

1+ Kbiasaa$ .riba"i .asi$11 A.aka- ba.ak

sri$% m$%k&$sumsiblab la

1 A.aka- ba.akmr&k&k/

PEMERIKSAAN TANDA VITAL5ika "i.rluka$ .@ 'a$"a 3i'al maka lam.irka$ klis' .mriksaa$ 'a$"a 3i'al

PEMERIKSAAN FISIK JANTUNG(li-a' klis .? kar"i&3askular)'ulis .mriksaa$ sik !a$% -arus "ilakuka$ ssuai "$%a$ .$!aki' lam.irka$

klis' .? .a"a -alama$ 'rak-irPEMERIKSAAN PENUNJANG





1 >i.r'$si B.-al%ia* Kuma-a+ Dama$%





19 EDUKASI

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