Lembar Anamnesa Dan Pemeriksaan Pasien Interna

 Anissa Citra Dewi, S.ked ---- is going to be a good doctor 

LEMBAR ANAMNESA DAN PEMERIKSAAN PASIEN INTERNA

MRS hari/tanggal/ruangan :………………………………………………………………………………………………………………………………… I.

Identitas pasien

=>

Nama : ………………………………………………………/…………. Umur : …..……………….. Alamat : ………………………………………………………………….. Agama : …………………… …………………… Pekerjaan : ………………………………………………………………. Status : …………………….

II.

Anamnesa => Keluhan Utama

: ……………………………………………………………………………………………………….

RPS : (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 : RR

:

mmHg,

Nadi :

x/menit

X/menit,

Suhu :

°C



Kulit

: ………………………………………………………………………………………………………………………………..



Kepala

: a/i/c/d……………………………………………………………………………………………………………………..



Leher

: ………………………………………………………………………………………………………………………………..



Thorak : Pulmo

:

Inspeksi : ………………………………………………………………………………………………………. Palpasi : ……………………………………………………………………………………………………….. ………………………………………………………………………………………………………..

Perkusi : ………..…………………………………………………………………………………………….. .………………………………………………………………………………………………………. Auskultasi : ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. 

Thorak : Jantung

:

Inspeksi : ……………………………………………………………………………………………………….

Palpasi : ……………………………………………………………………………………………………….. ………………………………………………………………………………………………………..

Perkusi : ……………………………………………………………………………………………………….. ……………………………………………………………………………………………………….. ……………………………………………………………………………………………………….. ……………………………………………………………………………………………………….. Auskultasi : ………………………………………………………………………………………………….. …………………………………………………………………………………………………..

 Anissa Citra Dewi, S.ked ---- is going to be a good doctor  

Abdomen

:

Inspeksi : ………………………………………………………………………………………………………. Auskultasi : …………………………………………………………………………………………………..

Palpasi : ……………………………………………………………………………………………………….. ………………………………………………………………………………………………………..

Perkusi : ……………………………………………………………………………………………………….. 

Ektremitas sup et inf

: Akral hangat :

Kering :

Oedema : 

CRT :

Neurologi

: Kaku kuduk : …………………………………………………………………………………………………………..

Reflek fisiologis :

BPR

:

/

KPR

:

/

TPR

:

/

APR

:

/

:

Hoffman

:

/

Tromner

:

/

Babinsky

:

/

Chaddok

:

/

Reflek patologis

IV. Usulan laboratorium Hematologi -

Hb :

- Eritrosit :

-

Leukosit :

- Hematokrit :

-

Trombosit :

- LED :

Kimia darah - Bilirubin total/indirect/direct :

- GDA :

- SGOT/SGPT :

- G2jpp :

Serologi : IgG ( ), IgM ( ), DBT ( ), Widal test : Urinalisa : Feces Lengkap : V.

Usulan Penunjang 1. Foto Roentgen : 2. USG

:

3. EKG

:

4. dll

:

V. Dianosa Kerja

: ………………………………………………………………………………………………………………………………..

VI. Diagnosa Banding

: ………………………………………………………………………………………………………………………………..

VII. Usulan Terapi

: ………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………..

IX. Diagnosa akhir

: …………………………………………………………………………………………………………………………………

 Anissa Citra Dewi, S.ked ---- is going to be a good doctor 

LEMBAR SOAP PASIEN INTERNA

Identitas pasien Tgl

: Nama : ……………………………………… Umur : …………… Diagnosa : ……………………………….……………………. SUBJECT

OBJECT

ASSESSMENT

PLANNING