BAB I

STATUS PEDIATRIK
I.

IDENTITAS
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2.
3.
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6.
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8.
9.

II.

Nama
Umur
Jenis Kelamin
Nama Ayah
Nama Ibu
Bangsa
Alamat
Dikirim oleh
MRS Tanggal

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ANAMNESIS ( Subjektif / S)
Tanggal

Diberikan oleh :
A. Riwayat Penyakit Sekarang
1. Keluhan Utama :
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2. Keluhan tambahan :
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3. Riwayat Perjalanan Penyakit :
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B. Riwayat Penyakit Dahulu
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C. Riwayat Penyakit Keluarga
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D. Pedegree

E. Riwayat pribadi
Riwayat kehamilan
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Riwayat persalinan
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Riwayat pascalahir
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F. Riwayat Makan dan Minum Anak :
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G. Riwayat Pertumbuhan dan Perkembangan

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H. Riwayat Imunisasi
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I. Sosial Ekonomi dan Lingkungan
a. Social Ekonomi
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b. Lingkungan

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III. Pemeriksaan Fisik

1.

2.

Pemeriksaan Umum
Keadaan Umum :
Sensorium
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Tekanan darah :
Nadi
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Pernapasan
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Temperatur
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Berat badan
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Tinggi badan
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Pemeriksaan Khusus
Kepala : ..............................................................................................
Mata
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Hidung : ..............................................................................................
Mulut
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Telinga : ..............................................................................................
Leher
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Thorax : ..............................................................................................
Paru-paru :
Inspeksi
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Perkusi
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Auskultasi
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Jantung :
Inspeksi
Palpasi
Auskultasi

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Abdomen
Inspeksi

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Palpasi

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Perkusi

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Auskultasi

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Ginjal dan Urogenital : ......................................................................

Lambung dan Usus

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Endokrin

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Ekstremitas

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Alat Kelamin

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Status Neurologis

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IV. Pemeriksaan Penunjang

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V.

Diagnosis Banding
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VI. Diagnosis
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VII. Tatalaksana
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