Lampiran 1. RSUP Dr.

Wahidin Sudirohusodo
DATA PENDERITA No. RM: ____________
KARSINOMA PARU

A. Identitas
Nama : __________________________________ L / P
Umur : __________________________________ thn
Suku : __________________________________
Tlp./No.HP : __________________________________
Alamat : ___________________________________________________________________________
Pekerjaan : ___________________________________________________________________________
Penghasilan : __________________________________ per bulan

B. Anamnesis
Jenis perawatan: Rawat jalan / Rawat inap (tanggal MRS ____________ tanggal KRS ____________ )
Keluhan utama: _____________________________________________________ Lamanya: _______
(hr/bln/th)
Keluhan lain: Batuk + / - (____ hr/bln/th) Demam + / - (____ hr/bln/th)
Suara serak + / - (____hr/bln/th) Bengkak di wajah/badan + / - (_____hr/bln/th)
Sesak napas + / - (____ hr/bln/th) Hemoptisis + / - (____ hr/bln/th) Vol: _________
Nyeri dada + / - (____ hr/bln/th) Penurunan berat badan + / - (___ kg/____bln/th)
Lain-lain/Komplikasi: ________________________________________________________
Riw. Merokok: Aktif / Pasif Jenis: ______________ Lamanya: ___ (hr/bln/th) Jumlah: _______
batang/hari
Riw. Penyakit sebelumnya: Hipertensi + / - Lamanya: _______ (hr/bln/th)
Diabetes melitus + / - Lamanya: _______ (hr/bln/th)
Lain-lain: ________________________________ Lamanya: _______ (hr/bln/th)
Riw. Peny. keluarga: Tumor + / - _______________ (Hubungan keluarga: _____________
Hidup/Meninggal)
Lain-lain: ___________________ (Hubungan keluarga: _____________ Hidup/Meninggal)

C. Pemeriksaan Fisis
PS tampilan: ________ % TB _____ cm BB _____ kg IMT ______ kg/m2
TD: _________ mmH2O N ____ x/mnt P ____ x/mnt tipe _____________________ S ____ oC
Kepala/Leher: Anemis + / - Sklera ikterus + / - Bibir sianosis + / -
Deviasi trakea + / - kanan/kiri DVS R _____ cmH2O
Massa tumor + / - ______________________ Pembesaran KGB + / -
____________________
Pulmo: Inspeksi : Asimetris / Simetris _____________ Venaektasi + / - Retraksi sela iga + / -

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 Palpasi : Massa tumor + / - _________________ Nyeri tekan + / - regio : ____________
VF : ______________________________________________________________________________
Perkusi: __________________________________________________________________________
Auskultasi : BP: Vesikuler/Bronkial/Bronkovesikuler
Bunyi tambahan: Ronki + / - _________________ Wheezing + / - __________________
Jantung: Kardiomegali + / - BJ I/II reguler/ireguler HR: ____ x/mnt Bising + / -
_______________________
Abdomen: Supel / Distensi Hepatomegali + / - ________________ Splenomegali + / -
Suara usus + / - kesan menurun/normal/meningkat Massa tumor + / - ____________ Asites + /
-
Ekstremitas: Edema + / - ________________________ Clubbing finger + / -
__________________________

D. Laboratorium
Darah rutin: Hb ____ HCT _____ Lekosit __________ PLT _____________ LED I/II _______
Kimia darah rutin: GDS _____ SGOT/SGPT ________ Ureum/Kreatinin ________ Na _____ K _____ Cl _____
Prot tot ____ Albumin ____ Globulin ____ Bilirubin I/II ______ Lain-lain
_______________
Tumor marker: CEA ________ Lain-lain
________________________________________________________
Sitologi sputum: __________________________________________________________________________
E. Foto toraks
______________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
F. CT Scan toraks ___________________________________________________________________________
_______________________________________________________________________________________
G. EKG ___________________________________________________________________________________
H. Stadium (TNM) __________________________________________________________________________
I. Radiologi lain ____________________________________________________________________________
J. Patologi anatomi: Organ Asal ______________________ Hasil
_____________________________________
_______________________________________________________________________________________
K. Hasil Bronkoskopi
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Kesimpulan: _____________________________________________________________________________

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L. Patologi Anatomi
Laboratorium: _________________________________________ Nomor register:
_____________________
Asal organ: ______________________________________________________________________________
Fixasi: __________________________________________________________________________________
Hasil: __________________________________________________________________________________
_______________________________________________________________________________________

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