FAKULTAS KEDOKTERAN ……………..

SMF BEDAH RSUD. Dr. H. ABDUL MOELOEK

BANDAR LAMPUNG
STATUS MAHASISWA BEDAH
TANGGAL : ________________________
RUANG : ________________________
Nama Mahasiswa : ________________________
NPM : ________________________ Tanda Tangan : _________

IDENTITAS PASIEN
Nama : _________________ Jenis Kelamin : ___________________
Umur : _________________ Bangsa : ___________________
Pekerjaan : _________________ Agama : ___________________
Alamat : _________________ No. MR : ___________________

I. ANAMESIS
Diambil dari : __________________ Tanggal : ________________Jam : _______
1. Keluhan Utama
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2. Keluhan Tambahan
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3. Riwayat Penyakit
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4. Riwayat Keluarga :
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5. Riwayat masa lampau

a. Penyakit terdahulu : _______________________________________________
b. Trauma terdahulu : _______________________________________________
c. Operasi : _______________________________________________
d. Sistem saraf : _______________________________________________
e. Sistem Kardiovaskular : _______________________________________________
f. Sistem gastrointestinal : _______________________________________________
 g. Sistem urinarius : _______________________________________________
h. Sistem genitalis : _______________________________________________
i. Sistem muskuloskeletal : _______________________________________________
II. STATUS PRESENT

A. STATUS UMUM
Keadaan Umum : ________________________________
Kesadaran : ________________________________
Keadaan gizi : ________________________________
Kulit : ________________________________

B. PEMERIKSAAN FISIK

 TANDA VITAL
Tekanan Darah : ___________ mmHg Nadi : _____________X/ menit

Pernafasan : ___________ X/ menit Suhu : _____________ 0 C

 KEPALA DAN MUKA

o Bentuk dan Ukuran :
o Mata :

Konjungtiva : __________________ Reflek Cahaya : _________________

Sklera : __________________ Pupil : _________________

o Telinga : _________________________________________
o Hidung : _________________________________________
o Tenggorokan : _________________________________________
o Mulut : _________________________________________
o Gigi : _________________________________________

 LEHER
o Kelenjar Getah bening : _________________________________________
o Kelenjar Gondok : _________________________________________
o JVP :
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 DADA ( Thorax )
o Inpeksi :
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o Palpasi :
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o Perkusi :
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o Auskultasi :
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 PERUT ( ABDOMEN )
o Inpeksi :
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o Palpasi :
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o Perkusi :
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o Auskultasi :
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 REGIO LUMBAL ( FLANK AREA )
o Inpeksi :
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 o Palpasi :
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o Perkusi :
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o Auskultasi :
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 EKSTREMITAS
o Superior :
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o Inferior :
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 GENITALIA
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 PERIANAL
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 NEUROMUSKULAR
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o Sensibilitas :
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o Refleks fisiologis :
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o Refleks Patologis :
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 TULANG BELAKANG
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C. STATUS LOKALIS

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III. LABORATORIUM RUTIN :
A. Darah Rutin
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B. Urine Rutin
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C. Faces Rutin
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IV. RESUME
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V. DIAGNOSIS BANDING
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VI. DIAGNOSIS KERJA

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VII. PENATALAKSANAAN DAN PENGOBATAN

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VIII. PEMERIKSAAN PENUNJANG
A. RADIOLOGI
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B. LABORATORIUM KHUSUS
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IX. PEMERIKSAAN ANJURAN

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X. PROGNOSIS
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XI. TINJAUAN KEPUSTAKAAN ( PADA CASE REPORT )

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