Download - CONTOH PKL KOSONG.ppt
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PRESENTASI KASUS LANGSUNG
OlehWiwi Robiatul Adawiah
105103003423
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Identitas
Nama : Tempat/ tgl lahir (Umur) :Jenis Kelamin : Status perkawinan :Alamat : Bangsa :Agama :Pendidikan :Pekerjaan :
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ANAMNESIS
Tgl Keluhan UtamaKeluhan Tambahan
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Riwayat Penyakit Sekarang
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Riwayat Penyakit Dahulu
Riwayat Penyakit Keluarga
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PEMERIKSAAN FISIK
Status Generalisata Keadaan umum : Kesadaran : Berat badan : Tinggi badan : Tanda Vital
- Tekanan Darah :
- Nadi :
- Suhu :
- Frekuensi Nafas :
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Kepala : Normocephali, rambut hitam, distribusi merata, tidak mudah dicabut, tidak ada alopesia.
Mata : Konjungtiva anemis -/-, sklera ikterik -/-, pupil bulat isokor, RCL +/+, RCTL +/+.
Telinga : Normotia +/+, nyeri tekan pada tragus dan antitragus -/-, sekret -/-, serumen-/- (liang telinga
lapang). Hidung: Deviasi septum -/-, sekret -/-. Mulut : Bibir kering (-), lidah kotor (-), gigi berlubang (-), Tenggorok: Faring hiperemis (-), tonsil T1-T1. Leher : Bentuk simetris, trakea lurus di tengah, tidak
teraba pembesaran tiroid. KGB : KGB preaurikuler, retroaurikuler, submandibula,
submental, supraklavikula, dan oksipital tidak membesar
Kulit : Lihat status dermatologikus
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PEMERIKSAAN THORAKS
Jantung: - Inspeksi : Ictus Cordis tidak terlihat- Palpasi :- Perkusi :- Auskultasi : Bunyi jantung I-II reguler, murmur (-), gallop (-)
Paru- Inspeksi : Gerakan napas simetris saat dinamis- Palpasi - Perkusi - Auskultasi : Suara napas vesikuler +/+, rhonki -/-, wheezing-/-
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PEMERIKSAAN ABDOMEN- Inspeksi : Datar- Palpasi : Supel, tekanan turgor kulit baik, tidak teraba massa, Hepar dan Lien tidak teraba membesar.- Perkusi : - Aukultasi : bising usus (+) normal
Genital : Lihat status dermatologikusEkstremitas (atas – bawah): tidak ada deformitas,
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Diagnosis kerja
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Diagnosis banding
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Pemeriksaan anjuran
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UMUM
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MedikamentosaSistemikR/
mfla pulv dtd No. XV
∫ 3 dd pulv I pc
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Topikal
R/ ∫ 1 dd ue (seluruh badan 1x seminggu)
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IX. PROGNOSIS
• Ad vitam :
•Ad fungsionam :
•Ad sanationam :
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