8/17/2019 lembar followup bangsal singkat

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Identitas :

....................................................................................................................................................................................

Keluhan Utama :

R. Penyakit Sekarang :

....................................................................................................................................................................................

Pemeriksaan Fisik 

KU : HR : x/m RR : x/m T : ˚C

TD : / mmHg St. i!i :

Kulit : Ikterik " # Ptekie " # $kim%sis " # &ur&ura

" # $ritema " # Pustul " # ................................

Ke&ala : '%rm%(e&hali) Ram*ut hitam) +erata

C%r : I : Iktus k%rdis " #

  P : Iktus k%rdis " # di SIC " #

  P : ,atas -tas : SIC II PSS

  ,atas Kiri : SIC +CS

  ,atas Kanan : SIC I PSD

  - : ,0 I II n%rmal) all " #) +ur " #

+ata : K%n1ungti2a -nemis " / # Sklera ikterik " / #

  $dema &al&e*ra " / # +ata Cekung " / #

  Re3leks Cahaya " / #

-*d%men : I : Datar emas Simetris

  P : De3. +us(ular " # 'T " # -sites " #

  P : Tim&ani &ada sel. -*d%men

Hidung : Sekret " / # De3%rmitas " / # Cu&ing " / # - : ,U " # '

Telinga : Sekret " / # 'T Tragus " / # 'T mast%id " # $kstremitas : $dem " # -kral Hangat " # CRT 456

+ulut : Sian%sis " # ,i*ir kering " # idah k%t%r " #

  3aring hi&eremis " # T 7 T

ain7lain : ......................................................................

........................................................................................

eher : Pem*esaran K, " # kelen1ar tir%id ............... ........................................................................................

Pulm% : I : erak dinding dada ...............  P : Stem 3remitus ka 8 ki

  P : S%n%r diseluruh la&. Paru

  - : esikuler) 9i! " #) Rh%n " #

........................................................................................

........................................................................................

........................................................................................

........................................................................................

....................................................................................................................................................................................

Identitas :

....................................................................................................................................................................................

Keluhan Utama :

R. Penyakit Sekarang :

....................................................................................................................................................................................

KU : HR : x/m RR : x/m T : ˚C

TD : / mmHg St. i!i :

Kulit : Ikterik " # Ptekie " # $kim%sis " # &ur&ura

" # $ritema " # Pustul " # ................................

Ke&ala : '%rm%(e&hali) Ram*ut hitam) +erata

C%r : I : Iktus k%rdis " #

  P : Iktus k%rdis " # di SIC " #

  P : ,atas -tas : SIC II PSS  ,atas Kiri : SIC +CS

  ,atas Kanan : SIC I PSD

  - : ,0 I II n%rmal) all " #) +ur " #

+ata : K%n1ungti2a -nemis " / # Sklera ikterik " / #

  $dema &al&e*ra " / # +ata Cekung " / #

  Re3leks Cahaya " / #

-*d%men : I : Datar emas Simetris

  P : De3. +us(ular " # 'T " # -sites " #

  P : Tim&ani &ada sel. -*d%menHidung : Sekret " / # De3%rmitas " / # Cu&ing " / # - : ,U " # '

Telinga : Sekret " / # 'T Tragus " / # 'T mast%id " # $kstremitas : $dem " # -kral Hangat " # CRT 456

+ulut : Sian%sis " # ,i*ir kering " # idah k%t%r " #

  3aring hi&eremis " # T 7 T

ain7lain : ......................................................................

........................................................................................

eher : Pem*esaran K, " # kelen1ar tir%id ............... ........................................................................................Pulm% : I : erak dinding dada ...............

  P : Stem 3remitus ka 8 ki

........................................................................................

........................................................................................

8/17/2019 lembar followup bangsal singkat

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  P : S%n%r diseluruh la&. Paru

  - : esikuler) 9i! " #) Rh%n " #

........................................................................................

........................................................................................

Identitas :

....................................................................................................................................................................................

Keluhan Utama :

R. Penyakit Sekarang :

....................................................................................................................................................................................

Pemeriksaan Fisik 

KU : HR : x/m RR : x/m T : ˚CTD : / mmHg St. i!i :

Kulit : Ikterik " # Ptekie " # $kim%sis " # &ur&ura

" # $ritema " # Pustul " # ................................

Ke&ala : '%rm%(e&hali) Ram*ut hitam) +erata

C%r : I : Iktus k%rdis " #  P : Iktus k%rdis " # di SIC " #

  P : ,atas -tas : SIC II PSS

  ,atas Kiri : SIC +CS

  ,atas Kanan : SIC I PSD

  - : ,0 I II n%rmal) all " #) +ur " #

+ata : K%n1ungti2a -nemis " / # Sklera ikterik " / #

  $dema &al&e*ra " / # +ata Cekung " / #

  Re3leks Cahaya " / #

-*d%men : I : Datar emas Simetris

  P : De3. +us(ular " # 'T " # -sites " #

  P : Tim&ani &ada sel. -*d%men

Hidung : Sekret " / # De3%rmitas " / # Cu&ing " / # - : ,U " # '

Telinga : Sekret " / # 'T Tragus " / # 'T mast%id " # $kstremitas : $dem " # -kral Hangat " # CRT 456+ulut : Sian%sis " # ,i*ir kering " # idah k%t%r " #

  3aring hi&eremis " # T 7 T

ain7lain : ......................................................................

........................................................................................

eher : Pem*esaran K, " # kelen1ar tir%id ............... ........................................................................................Pulm% : I : erak dinding dada ...............

  P : Stem 3remitus ka 8 ki

  P : S%n%r diseluruh la&. Paru

  - : esikuler) 9i! " #) Rh%n " #

........................................................................................

........................................................................................

........................................................................................

........................................................................................

....................................................................................................................................................................................

Identitas :

....................................................................................................................................................................................

Keluhan Utama :

R. Penyakit Sekarang :

....................................................................................................................................................................................

KU : HR : x/m RR : x/m T : ˚C

TD : / mmHg St. i!i :

Kulit : Ikterik " # Ptekie " # $kim%sis " # &ur&ura

" # $ritema " # Pustul " # ................................

Ke&ala : '%rm%(e&hali) Ram*ut hitam) +erata

C%r : I : Iktus k%rdis " #

  P : Iktus k%rdis " # di SIC " #

  P : ,atas -tas : SIC II PSS

  ,atas Kiri : SIC +CS

  ,atas Kanan : SIC I PSD

  - : ,0 I II n%rmal) all " #) +ur " #

+ata : K%n1ungti2a -nemis " / # Sklera ikterik " / #

  $dema &al&e*ra " / # +ata Cekung " / #

  Re3leks Cahaya " / #

-*d%men : I : Datar emas Simetris

  P : De3. +us(ular " # 'T " # -sites " #

  P : Tim&ani &ada sel. -*d%menHidung : Sekret " / # De3%rmitas " / # Cu&ing " / # - : ,U " # '

Telinga : Sekret " / # 'T Tragus " / # 'T mast%id " # $kstremitas : $dem " # -kral Hangat " # CRT 456

+ulut : Sian%sis " # ,i*ir kering " # idah k%t%r " #

  3aring hi&eremis " # T 7 T

ain7lain : ......................................................................

........................................................................................

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eher : Pem*esaran K, " # kelen1ar tir%id ............... ........................................................................................

Pulm% : I : erak dinding dada ...............

  P : Stem 3remitus ka 8 ki

  P : S%n%r diseluruh la&. Paru

  - : esikuler) 9i! " #) Rh%n " #

........................................................................................

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