Lembar Anamnesa Dan Pemeriksaan Pasien Interna [PDF]

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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