STATUS PASIEN BAGIAN ILMU PENYAKIT MATA

P3D FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM BANDUNG

ANAMNESA
-

KELUHAN UTAMA

ANAMNESA KHUSUS

RIWAYAT PENYAKIT DAHULU

RIWAYAT GIZI

KEADAAN SOSIAL EKONOMI

PENYAKIT SISTEMIK
TRACT RESPIRASI
TRACT DIGESTIVE
CARDIO VASKULAR
ENDOKRINE
NEUROLOGY
KULIT
THT
GIGI DAN MULUT

NAMA
:
RUANGAN :
TANGGAL :

UMUR:
NO RM:

 LAIN-LAIN
I. PEMERIKSAAN UMUM
- TINGGI BADAN
- BERAT BADAN
- TEKANAN DARAH
- NADI
- SUHU
- PERNAFASAN
- CARDIO VASCULAR
- G.I. TRACT
- PARU-PARU
- NEUROLOGY

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II. PEMERIKSAAN VISUS DAN REFRAKSI

- VISUS
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CC
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STEN
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KOREKSI

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C.

as.

Add:S..
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MUSCLE BALANCE

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S...........

C.

as.

Add: S....

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PERGERAKAN BOLA MATA :......

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III. PEMERIKSAAN EKSTERNAL

PALPEBRA SUPERIOR
PALPEBRA INFERIOR
CILIA
AP. LACRIMALIS
CONJ. TARS. SUPERIOR
CONJ. TARS. INFERIOR
CONJ. BULBI
CORNEA

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KAMAR DEPAN
PUPIL
DIAMETER

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REFLEX CAHAYA
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Direct
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Konsensuil
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- IRIS
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- LENSA
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- LAIN-LAIN
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IV. PEMERIKSAAN SLIT LAMP DAN BIOMICROSCOPY
- CILIA
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- CONJUNCTIVA
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- CORNEA
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- KAMAR DEPAN
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- IRIS
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- LENSA
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V. TONOMETRI
- PALPASI
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- SCHIOTZ
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VI. GONIOSCOPY
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VII. VISUAL FIELD
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VIII. PEMERIKSAAN PADA KEADAAN MIDRIASIS

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FUNDUSKOPI
PAPIL
A/V RATIO :
C/D RATIO:
RETINA:
MACULA :

IX. PEMERIKSAAN LAIN-LAIN

MEDIA.....

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MEDIA.....

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X. RESUME:
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XI. DIAGNOSIS KERJA
XII.

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DIFFERENSIAL DIAGNOSIS
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XIII. RENCANA PEMERIKSAAN : ..
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XIV. RENCANA THERAPY

XV.

RENCANA OPERASI

XVI. PROGNOSA

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NAMA KOAS :
NPM

KEGIATAN

PRESEPTOR :