PEMERINTAH KOTA SIBOLGA

RSU DR. FERDINAND LUMBANTOBING

ASESMEN MEDIS RAWAT JALAN

PASIEN PENYAKIT DALAM

NO.RM
NAMA
UMUR
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ALAMAT

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Di isi oleh Dokter

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TANGGAL : :................................
A. ANAMNESA
1. Keluhan Utama :
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2. Riwayat Penyakit Dahulu :
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3. Riwayat Penyakit Sekarang :
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4. Riwayat Penyakit Keluarga :
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B. PEMERIKSAAN FISIK.
1. Vital Sign :
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2. Cranium :
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3. Leher :
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4. Thorax :
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5. Abdomen :................................................................................................................................
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6. Genitalia : ...............................................................................................................................
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7. Extremitas :
a. Ext. Atas : ............................................................................................................................
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b. Ext. Bawah : .........................................................................................................................
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C. DIAGNOSTIK PENUNJANG.
1. Laboratorium :...........................................................................................................................
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2. Radiologi : ................................................................................................................................
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3. USG................................................................................................................................
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4. EKG................................................................................................................................
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D. DIAGNOSA BANDING:
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E. DIAGNOSA KERJA :
E. THERAPI. : ....................................................................................................................................
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Dokter Penanggung Jawab Pasien

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