DEPARTEMEN PENDIDIKAN NASIONAL

FAKULTAS KEDOKTERAN UNIVERSITAS ALKHAIRAAT

Bag./SMF Ilmu Kesehatan Kulit & Kelamin FK UNISA Palu / RSU Anutapura

STATUS PENDERITA

Diagnosis : __________________________

Nama : ___________________________

NIM : ___________________________

Pembimbing : ___________________________
1. Nama : ………………………………………………………………....
Umur : ………………………………………………………………....
Alamat : ……………………………………………………………........
Status Perkawinan : ……………………………………………………………........
Tgl. Masuk Rs/Poli : ……………………………………………………………........

2. Anamnesis : ………………………………………………………………....
Keluhan Utama : ………………………………………………………………....
Anamnesis Terpimpin : ……………………………………...........................................
……………………………………………………………………………......................
……………………………………………………………………………......................
……………………………………………………………………………......................
……………………………………………………………………………......................
……………………………………………………………………………......................
……………………………………………………………………………......................
……………………………………………………………………………......................
……………………………………………………………………………......................
……………………………………………………………………………......................
……………………………………………………………………………......................

3. Status Pasien
Keadaan Umum : Sakit (Ringan/Sedang/Berat) ; Kesadaran : …………………
Gizi (Kurang/Cukup/Baik) ; Higiene (Buruk/Sedang/Baik)
Tanda Vital : Tensi ………… mm/Hg ; Nadi ………… x/mnt ;
Pernapasan …………. x/mnt ; Suhu ………….. oC
Kepala : * Sklera : Ikterus (+/-)
 Konjungtiva : Anemia (+/-)
 Bibir : Sianosis (+/-)
Jantung / Paru : …………………………………………………………………
Abdomen :…………………………………………………………………
Ekstremitas : …………………………………………………………………
Kelenjar Limfa : …………………………………………………………………

4. Status Lokalis : Kepala, Dada, Punggung, Bokong, Genetalia, Ekstremitas

(Superior/ inferior)
5. Status Dermatologi – Venereologi
Lokasi : …………………………………………………………………
Ukuran :
…………………………………………………………………
Efloresensi : …………………………………………………………………

6. Laboratorium
Kerokan : …………………………………………………………………
Dan lain-lain : …………………………………………………………………

7. Resume : …………………………………………………………………
………………………………………………………………………………...........…...
………………………………………………………………………………………......
…………………………………………………………………………………………..
…………………………………………………………………………………………..
…………………………………………………………………………………………..
…………………………………………………………………………………………..
…………………………………………………………………………………………..
………………………………………………………………………………………….
………………………………………………………………………………………...
………………………………………………………………………………………......
………………………………………………………………………………………......
………………………………………………………………………………………......
………………………………………………………………………………………….

8. Diagnosis Banding : …………………………………………………………………

9. Diagnosis : …………………………………………………………………
10. Diskusi : …………………………………………………………………
…………………………………………………………………………………………..
…………………………………………………………………………………………..
…………………………………………………………………………………………..
…………………………………………………………………………………………..
…………………………………………………………………………………………..
 …………………………………………………………………………………………..
…………………………………………………………………………………………
……………………………………………………………………………… …………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………

11. Anjuran Pemeriksaan : …………………………………………………………………

12. Terapi
Sistemik : …………………………………………………………………

…………………………………………………………………..
......................................................................................................
......................................................................................................
Topikal :…………………………………………………………………

…………………………………………………………………..
......................................................................................................
......................................................................................................

13. Prognosis : …………………………………………………………………

………………………………………………………….......….