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LEMBAR ANAMNESA DAN PEMERIKSAAN PASIEN MRS hari/tanggal/ruangan :………………………………………………………………………………………………………………………………… I.
Identitas pasien
II.
Anamnesa => Keluhan Utama RPS
=>
Nama : ………………………………………………………/…………. Umur : …..……………….. Alamat : ………………………………………………………………….. Agama : …………………… Pekerjaan : ………………………………………………………………. Status : ……………………. : ……………………………………………………………………………………………………….
: (onset, frekuensi, kualitas, kuantitas, kronologis, gejala tambahan, gejala yg memperingan dan memperberat, riwayat pengobatan) …………………………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………….
RPD
: ………………………………………………………………………………………………………………………………………………………….
RPK
: ………………………………………………………………………………………………………………………………………………………….
Riwayai sosial : ……………………………………………………………………………………………………………………………………………….. III.
Pemeriksaan Fisik Keadaan umum Kesadaran Vital sign
: ………………………………………………………………………………………………………………………………… : ……………………………………………………………………………………………………………………………….. : Tensi : mmHg, Nadi : x/menit RR
Kulit Kepala Leher Thorak : Pulmo
Thorak : Jantung
Abdomen
Ektremitas sup et inf Neurologi Reflek fisiologis : Reflek patologis
:
X/menit,
Suhu :
°C
: ……………………………………………………………………………………………………………………………….. : a/i/c/d…………………………………………………………………………………………………………………….. : ……………………………………………………………………………………………………………………………….. : Inspeksi : ………………………………………………………………………………………………………. Palpasi : ……………………………………………………………………………………………………….. ……………………………………………………………………………………………………….. Perkusi : ………..…………………………………………………………………………………………….. .………………………………………………………………………………………………………. Auskultasi : ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. : Inspeksi : ………………………………………………………………………………………………………. Palpasi : ……………………………………………………………………………………………………….. ……………………………………………………………………………………………………….. Perkusi : ……………………………………………………………………………………………………….. ……………………………………………………………………………………………………….. ……………………………………………………………………………………………………….. ……………………………………………………………………………………………………….. Auskultasi : ………………………………………………………………………………………………….. …………………………………………………………………………………………………..
:
Inspeksi : ………………………………………………………………………………………………………. Auskultasi : ………………………………………………………………………………………………….. Palpasi : ……………………………………………………………………………………………………….. ……………………………………………………………………………………………………….. Perkusi : ……………………………………………………………………………………………………….. : Akral hangat : Kering : Oedema : CRT : : Kaku kuduk : ………………………………………………………………………………………………………….. BPR : / KPR : / TPR : / APR : / : Hoffman : /
Tromner Babinsky Chaddok
IV. Usulan laboratorium Hematologi - Hb : - Leukosit : - Trombosit : Kimia darah - Bilirubin total/indirect/direct : - SGOT/SGPT : Serologi : IgG ( ), IgM ( ), DBT ( ), Widal test : Urinalisa : Feces Lengkap : V. Usulan Penunjang 1. Foto Roentgen : 2. USG : 3. EKG : 4. dll :
: : :
/ / / - Eritrosit : - Hematokrit : - LED : - GDA : - G2jpp :
V. Dianosa Kerja
: ………………………………………………………………………………………………………………………………..
VI. Diagnosa Banding
: ………………………………………………………………………………………………………………………………..
VII. Usulan Terapi
: ………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………..
IX. Diagnosa akhir
: …………………………………………………………………………………………………………………………………
LEMBAR SOAP PASIEN INTERNA Identitas pasien Tgl
: Nama : ……………………………………… Umur : …………… Diagnosa : ……………………………….…………………….
SUBJECT
OBJECT
ASSESSMENT
PLANNING