Anamnesis:___________________________________________________________________________________

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1. Keadaan umum : __________________________________

2. Kesadaran :___________________________________
3. Berat badann :___________________________________
4. Tinggi badan :___________________________________
5. Imt :___________________________________
6. Status gizi :___________________________________
7. Tanda vital
Tekanan darah :____________________________
Nadi :____________________________
Suhu : ___________________________
Pernafasan :____________________________

Kepala
:_________________________________________________________________________________________

Kulit
:_________________________________________________________________________________________

Mata
:_________________________________________________________________________________________

Telinga
:________________________________________________________________________________________

Hidung
:________________________________________________________________________________________

Mulut
:_________________________________________________________________________________________

Leher
:_________________________________________________________________________________________

Thoraks
:_______________________________________________________________________________________

Pulmo

Paru-paru depan : I:__________________________________________________________________________

P:__________________________________________________________________________
 P:__________________________________________________________________________

A: vesikuler ( / ), wheezing : rhonki :

Paru-paru belakang :
I:___________________________________________________________________________

P:___________________________________________________________________________

P:___________________________________________________________________________

A: vesikuler ( / ) wheezing : rhonki :

Jantung :
I:_________________________________________________________________________________

P:_________________________________________________________________________________

P: batas jantung kanan

:_____________________________________________________________
Batas jantung kiri
:_____________________________________________________________
Batas jantung atas
:_____________________________________________________________
Batas jantung bawah
:______________________________________________________________

A:_________________________________________________________________________________

Abdomen :
I:_________________________________________________________________________________

A:_________________________________________________________________________________

P:_________________________________________________________________________________
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P:_________________________________________________________________________________

Pemeriksaan khusus :
Punggung :
I:_________________________________________________________________________________

P:_________________________________________________________________________________

Ekstrmitas : CRT < 2 detik

superior Inferior
Edema
Sianosis
Akral
Tonus
Tremor
Refleks fisiologi :
Bisep
Trisep
Lutut
Achiles
Refleks patologis :
Babinski
Chaddock
Oppenheim
Hoffman tromner