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STATUS ILMU PENYAKIT KULIT DAN KELAMIN

SMF PENYAKIT KULIT DAN KELAMIN

RUMAH SAKIT PUSAT ANGKATAN UDARA JAKARTA

Nama Mahasiswa :.....................................................Tanggal :........................................

NIM :.....................................................TTD :........................................

Do!"# P"m$im$ing : %. . D"wi Angg#"ni' S(.KK

). . Iwan T#iha(so#o' S(.KK

*. . A.A. S#i +,&h-ani

I. IDENTITAS PASIEN

No. RM :.................................................................................................................

Nama :.................................................................................................................

Um,# :.......................................................................................................!ah,n

J"nis "lamin :.................................................................................................................

S,, +angsa :.................................................................................................................

S!a!,s P"#awinan :.................................................................................................................

Alama! :.................................................................................................................

T"l(. :.................................................................................................................

Agama :.................................................................................................................

P""#aan :.................................................................................................................

Ho$i :.................................................................................................................

P"n&i&ian :.................................................................................................................

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II. ANAMNESIS

Dila,an s"/a#a...................................................(a&a !anggal.........................(,,l........:........

K"l,han U!ama :

Riwa-a! P"n-ai! S"a#ang :

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III. PEMERIKSAAN UMUM

K"sa&a#an :.................................................................................................................

T"anan Da#ah :......................................................................................................mmHg

Na&i :.....................................................................................................12m"ni!

S,h, :.............................................................................................................34

P"#na5asan :.....................................................................................................12m"ni!

K"a&aan Um,m :.................................................................................................................

K"a&aan Gi6i :.................................................................................................................

Tinggi +a&an :............................................................................................................/m

+"#a! +a&an :.............................................................................................................g

I7. PEMERIKSAAN FISIK

K"(ala :

Ma!a :

8aah :

L"h"# :

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Tho#a1 :

A$&om"n :

Es!#"mi!as :

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7. STATUS DERMAT9L9GIKUS

a. Loasi 2 R"gio :

$. E5lo#"s"nsi :

P#im"# :

S",n&"# :

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7I. PEMERIKSAAN PENUNJANG

7II. DIAGN9SIS +ANDING

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). Sis!"mi

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*. Tin&aan

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. PEN4EGAHAN

I. K9MPLIKASI

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Diagnosis +an&ing

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Fo!o