BAGIAN/SMF ILMU KESEHATAN ANAK DAN REMAJA

RSUD dr. DORIS SYLVANUS PALANGKA RAYA

PROGRAM STUDI PENDIDIKAN DOKTER
UNIVERSITAS PALANGKA RAYA

STATUS DOKTER MUDA

KEPANITERAAN KLINIK

Nama Mahasiswa : NIM :

Hari/Tanggal : Paraf :

STATUS UMUM ANAK

IDENTITAS
1. Identitas Penderita
Nama penderita : .......................................................................................................................
Jenis kelamin : .......................................................................................................................
Tempat Tanggal Lahir : ................................................................. Umur : ....... Tahun ........ Bulan
2. Identitas Orang Tua/Wali
Ayah : Nama : .......................................................................................................................
Pendidikan : .......................................................................................................................
Pekerjaan : .......................................................................................................................
Alamat : .......................................................................................................................
Ibu : Nama : .......................................................................................................................
Pendidikan : .......................................................................................................................
Pekerjaan : .......................................................................................................................
Alamat : .......................................................................................................................

ANAMNESIS
Kiriman dari : .......................................................................................................................
Dengan diagnosis : .......................................................................................................................
Alloanamneis dengan : .......................................................................................................................
Tanggal/Jam diperiksa : .......................................................................................................................
1. Keluhan Utama : .......................................................................................................................
2. Riwayat Penyakit Sekarang : .....................................................................................................................
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3. Riwayat Penyakit Dahulu : (beri tanda centang pada penyakit yang pernah dialami)
Campak Difteri Kuning
Batuk Rejan Tetanus Cacingan
TBC Diare Kejang
Demam Tifoid ISPA DBD
Sesak Malaria ...........
4. Riwayat kehamilan dan persalinan
- Riwayat Antenatal : .......................................................................................................................
- Riwayat Natal : .......................................................................................................................
- Nilai Apgar : .......................................................................................................................
- Berat Badan Lahir : .......................................................................................................................
- Panjang Badan lahir : .......................................................................................................................
- Lingkar Kapala : .......................................................................................................................
- Penolong : .......................................................................................................................
- Tempat : .......................................................................................................................
- Riwayat Neonatal : .......................................................................................................................

5. Riwayat Perkembangan
- Tiarap : ................................................................................................. Bulan/Tahun
- Merangkak : ................................................................................................. Bulan/Tahun
- Duduk : ................................................................................................. Bulan/Tahun
- Berdiri : ................................................................................................. Bulan/Tahun
- Berjalan : ................................................................................................. Bulan/Tahun
- Saat Ini : ......................................................................................................................

6. Riwayat Imunisasi
Jenis Umur waktu pemberian (dalam hari/bulan)
BCG
Polio
Hepatitis B
DPT
Campak

7. Riwayat Makan (tulis jenis, kualitas, kuantitas, dan umur) :

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8. Riwayat Keluarga
Ikhtisar Keturunan : (gambar skema keluarga dan beri tanda keluarga yang menderita penyakit sejenis)
 Susunan Keluarga :
No L/ Jelaskan:
Nama Umur
. P Sehat / Sakit (apa) / Meninggal (umur/Sebab)
1.
2.
3.
4.
5.
6.

9. Riwayat Sosial dan Lingkungan

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PEMERIKSAAN FISIK
1. Keadaan Umum : ..................................................................................................................................
Kesadaran : Compos mentis / Apatis / Somnolen / Stupor / Koma
GCS : ..................................................................................................................................

2. Pengukuran
Tanda Vital : Tensi : .................................... mmHg
Nadi : .................................... x/Menit
Suhu : .................................... oC
Respirasi : .................................... x/Menit
BB : ...................... kg ( ............................. % standar BB/U)
TB/PJ : ...................... cm ( ............................. % standar PB-TB/U)
Lila : ...................... cm (untuk > 5 tahun)
Lingkar kepala : ...................... cm

3. Kulit
Warna : ..................................................................................................................................
Sianosis : ..................................................................................................................................
Hemangioma : ..................................................................................................................................
Turgor : ..................................................................................................................................
Kelembapan : ..................................................................................................................................
Pucat : ..................................................................................................................................
Lain-lain : ..................................................................................................................................

4. Kepala
Bentuk : ..................................................................................................................................
UUB : ..................................................................................................................................
UUK : ..................................................................................................................................
Lain-lain : ..................................................................................................................................

Rambut
Warna : ..................................................................................................................................
Tebal/Tipis : ..................................................................................................................................
Distribusi : ..................................................................................................................................
Alopesia : ..................................................................................................................................
Lain-lain : ..................................................................................................................................

Mata
Palpebra : ..................................................................................................................................
Alis, Bulu Mata : ..................................................................................................................................
Konjungtiva : ..................................................................................................................................
Sklera : ..................................................................................................................................
Produksi air mata : ..................................................................................................................................
Pupil : Diameter : .................................................................................................................
Simetris : .................................................................................................................
Refleks : .................................................................................................................
Kornea : ..................................................................................................................................

Telinga
Bentuk : ..................................................................................................................................
Sekret : ..................................................................................................................................
Serumen : ..................................................................................................................................
Nyeri : .......................................................... Lokasi : ..........................................................

Hidung
Bentuk : ..................................................................................................................................
Pernapasan cuping hidung : .......................................................................................................................
Epistaksis : ..................................................................................................................................
Sekret : ..................................................................................................................................

Mulut
Bentuk : ..................................................................................................................................
Bibir : ..................................................................................................................................
Gusi : Mudah Berdarah / tidak
Pembengkakan + / -
Gigi geligi : ..................................................................................................................................

Lidah
Bentuk : ..................................................................................................................................
Pucat :+/-
Tremor :+/-
Kotor :+/-
Warna : ..................................................................................................................................

Faring
Hiperemi :+/-
Edema :+/-
Membran/Pseudomembran : + / -

Tonsil
Warna : ..................................................................................................................................
 Pembesaran : ..................................................................................................................................
Abses :+/-
Membran/Pseudomembran : + / -
5. Leher
Vena Jugularis : Pulsasi :+/
Tekanan :
Pembesaran kelenjar leher : .......................................................................................................................
Kaku kuduk : .......................................................................................................................
Massa : .......................................................................................................................
Tortikalis : .......................................................................................................................

6. Thoraks
Dinding dada / Paru
Inspeksi : Bentuk : ...........................................................................................................
Retraksi : ...........................................................................................................
Dispnea : ...........................................................................................................
Pernapasan : ...........................................................................................................
Palpasi : Fremitus fokal : ...........................................................................................................
Perkusi : ...........................................................................................................
Auskultasi : Suara Napas dasar : ...............................................................................................
Suara Napas tambahan : ...............................................................................................

Jantung
Inspeksi : Ictus Cordis : ...........................................................................................................
Palpasi : Apeks : ...........................................................................................................
Thrill : ...........................................................................................................
Auskultasi : Frekuensi : ...........................................................................................................
Suara dasar : ...........................................................................................................
Bising : .......................................... Derajat : ...................................
Lokasi : ...................................
Punctum Max : ...................................
Penyebaran : ...................................

7. Abdomen
Inspeksi : Bentuk : .......................................................................................................................
Lain-lain : .......................................................................................................................
Auskultasi :
Palpasi : Hati : .......................................................................................................................
Limpa : .......................................................................................................................
Ginjal : .......................................................................................................................
Massa : ................................................. Ukuran : ............................................
Lokasi : ............................................
Permukaan : ............................................
Konsistensi : ............................................
Nyeri : ............................................
Perkusi : Timpani / Pekak : ...........................................................................................................
Asites : ...........................................................................................................

8. Ekstremitas
Umum : ...............................................................................................................................................
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Neurologis :
No Lengan Tungkai
Pemeriksaan
. Kanan Kiri Kanan Kiri
1. Gerakan
2. Tonus
3. Trofi
4. Klonus
5. Refleks Fisiologis
6. Refleks Patologis
7. Sensibilitas
8. Tanda Meningeal

9. Susunan Saraf : ...................................................................................................................................

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10. Genitalia : ...................................................................................................................................
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11. Anus : ...................................................................................................................................

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PEMERIKSAAN LABORATORIUM SEDERHANA

1. Darah : ...................................................................................................................................
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2. Urine : ...................................................................................................................................
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3. Feses : ...................................................................................................................................
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RESUME

Nama : .......................................................................................................................
Jenis kelamin : .......................................................................................................................
Umur : .......................................................................................................................
Berat Badan : .......................................................................................................................
Keluhan Utama : .......................................................................................................................
Uraian : .....................................................................................................................
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Pemeriksaan Fisik
Kesadaran Umum : ...................................................................................................................................
Kesadaran : ...................................................................................................................................
Tensi : ...................................................................................................................................
Denyut Nadi : ...................................................................................................................................
Pernapasan : ...................................................................................................................................
Suhu : ...................................................................................................................................
Kulit : ...................................................................................................................................
Kepala : ...................................................................................................................................
Mata : ...................................................................................................................................
Telinga : ...................................................................................................................................
Mulut : ...................................................................................................................................
Thoraks/Paru : ...................................................................................................................................
Jantung : ...................................................................................................................................
Abdomen : ...................................................................................................................................
Ekstremitas : ...................................................................................................................................
Susunan Saraf : ...................................................................................................................................
Genitalia : ...................................................................................................................................
Anus : ...................................................................................................................................
DIAGNOSA
Diagnosa Banding : ..................................................................................................................................
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Diagnosa Kerja : ..................................................................................................................................
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Status Gizi : ..................................................................................................................................
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PENATALAKSANAAN
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USULAN PEMERIKSAAN
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PROGNOSIS
Qua ad vitam : ...................................................................................................................................
Qua ad functionam : ...................................................................................................................................
Qua ad sanationam : ...................................................................................................................................

PENCEGAHAN
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