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STATUS POMR
MAHASISWA PROGRAM PENDIDIKAN DOKTER SPESIALIS
PRODI ILMU PENYAKIT DALAM
FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN
PERIODE : ..................................................................
NOMOR URUT PASIEN: ......
No Reg. RS :…………………………..( RS ..................................................................... )
STATUS PASIEN : RAWAT JALAN / RAWAT INAP
Nama Lengkap :
Tanggal lahir :
Umur : tahun Jenis kelamin : L / P
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Alamat : Nomor telepon
Pekerjaan : Status : Belum menikah / Menikah / Janda / Duda
Pendidikan : Etnis / Suku : Agama :
Nama Asisten No. CHS Tanggal Pemeriksaan
ANAMNESIS
Autoanamnesis Alloanamnesis
RIWAYAT PENYAKIT SEKARANG
Keluhan Utama : ______________________________________________________
Riwayat perjalanan penyakit :
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RIWAYAT PENYAKIT DAHULU
Tanggal Penyakit Tempat Perawatan Pengobatan / Operasi
RIWAYAT PRIBADI
Riwayat Alergi Riwayat Imunisasi
Tahun Bahan/Obat Gejala Tahun Jenis Imunisasi
Hobi :___________________________________________________________
Olah Raga : ___________________________________________________________
Kebiasaan Makan : ___________________________________________________________
Merokok : ___________________________________________________________
Minum Alkohol : ___________________________________________________________
Hubungan Seks : ___________________________________________________________
Penggunaan Obat-obatan : ___________________________________________________________
DESKRIPSI UMUM
Kesan Sakit : ringan / sedang / berat
Gizi :
Berat Badan : …………… Kg; Tinggi badan : ……………… cm; IMT :
2
…………………Kg/m
TANDA VITAL
Kesadaran :
Nadi Frekuensi :…………………. / menit, Deskripsi :
Tekanan Darah Berbaring Duduk mmHg
o
Temperatur Aksilla : Rektal : C
Pernafasan Frekuensi :………………./ menit Deskripsi :
PEMERIKSAAN FISIK :
Kepala dan Leher
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Thorax Kiri Kanan
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Jantung
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Paru-paru
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Abdomen
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Ekstremitas
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Rektum
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Status Lokalis
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[Link]........................... [Link] record.................... Inisial peserta PPDSSp1............../tgl...................
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Pemeriksaan Penunjang
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[Link]........................... [Link] record.................... Inisial peserta PPDSSp1............../tgl...................
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RESUME DATA DASAR
(Diisi Dengan Temuan Positif)
1. KELUHAN UTAMA :
2. ANAMNESIS : (Riwayat Penyakit Sekarang, Riwayat Penyakit Dahulu, Riwayat Pengobatan,
Riwayat Keluarga, dll)
3. PEMERIKSAAN FISIK
4. PEMERIKSAAN PENUNJANG
5. LAIN-LAIN
MASALAH DAN PENGKAJIAN
1. Masalah :
Pengkajian :
2. Masalah :
Pengkajian :
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3. Masalah :
Pengkajian :
4. Masalah :
Pengkajian :
5. Masalah :
Pengkajian :
6. Masalah :
Pengkajian :
Makassar, .............................. 20...
Dibuat oleh, Diperiksa dan disetujui oleh,
(____________________________) (_______________________________)
MPPDS Supervisor
[Link]........................... [Link] record.................... Inisial peserta PPDSSp1............../tgl...................