BAB I

STATUS PEDIATRIK

I. IDENTITAS

1. Nama :

2. Umur :

3. Jenis Kelamin :

4. Nama Ayah :

5. Nama Ibu :

6. Bangsa :

7. Alamat :

8. Dikirim oleh :

9. MRS Tanggal :

II. ANAMNESIS ( Subjektif / S)

Tanggal :

Diberikan oleh :

A. Riwayat Penyakit Sekarang

1. Keluhan Utama :

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2. Keluhan tambahan :

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3. Riwayat Perjalanan Penyakit :

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B. Riwayat Penyakit Dahulu

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C. Riwayat Penyakit Keluarga

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D. Pedegree

E. Riwayat pribadi

Riwayat kehamilan

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Riwayat persalinan

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Riwayat pascalahir

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F. Riwayat Makan dan Minum Anak :

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G. Riwayat Pertumbuhan dan Perkembangan

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H. Riwayat Imunisasi

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I. Sosial Ekonomi dan Lingkungan

a. Social Ekonomi

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b. Lingkungan

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III. Pemeriksaan Fisik

1. Pemeriksaan Umum

Keadaan Umum :

Sensorium :

Tekanan darah :

Nadi :

Pernapasan :

Temperatur :

Berat badan :

Tinggi badan :

2. Pemeriksaan Khusus

Kepala : ..............................................................................................

Mata : ..............................................................................................

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Hidung : ..............................................................................................

Mulut : ..............................................................................................

Telinga : ..............................................................................................

Leher : ..............................................................................................

Thorax : ..............................................................................................

Paru-paru :

Inspeksi : ......................................................................

Perkusi : ......................................................................

Auskultasi : ......................................................................

Jantung :

Inspeksi : ......................................................................

Palpasi : ......................................................................

Auskultasi : ......................................................................

Abdomen

Inspeksi : ..................................................................................

Palpasi : ..................................................................................

Perkusi : ..................................................................................

Auskultasi : ..................................................................................

Ginjal dan Urogenital : ......................................................................

Lambung dan Usus : ......................................................................

Endokrin : ......................................................................

Ekstremitas : ......................................................................

Alat Kelamin : ......................................................................

Status Neurologis :

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IV. Pemeriksaan Penunjang

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V. Diagnosis Banding

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VI. Diagnosis

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VII. Tatalaksana

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