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      Data Ofine Surveilans PTM berbasis F

    No

    1   19 November 2015

    2   19 November 2015   43271-20-131 3510116805770001

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    2930

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    3940

    41

    TanggalPemeriksaan *

    IDENTITAS

    No RekamMeis

    No KTP *

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      TP

    Nama Pasien Tem!at "a#ir Tanggal "a#ir

     YULI NESIYAM E. P BANYUAN!I

    SI"I #$SAEMA P BANYUAN!I 28 M%& 1977

     $enisKelamin

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    Alamat "engka! No %P No Tel!& Ruma#

    '(A)AN 4*3 'ALIBA(U 'UL$N

    BA(U(E)$ 2*1 'ALIBA(U MANIS

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    Status Suku Peker'aan

    Me+,% )AA I("*",/% Beer%

    Me+,% )AA I("*",/% Beer%

    (olonganDara#

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    )A)ANARA IMT

    Keterangan Merokok  

     ",/% ",/% ",/% ",/% 150 55

     ",/% ",/% ",/% ",/% 150 60

    KurangAktivitas

    Fisik 

    KurangMakan

    Sa+ur

    KonsumsiAlko#ol

    Tinggi,aan

    ,erat,aan

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    Tekanan Dara# (ula Dara# Kolesterol

    Sistol Diastol Trigliseria

    120 80

    120 80

    "ingkarPerut

    (ula Dara#Se-aktu

    (ula Dara#Puasa

    KolesterolTotal

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    "D" %D"

    ArusPun.ak

    Eks!irasi/APE0

    KaarAlko#ol

    Perna1asan

    TesAm1etamin

    2rin

    ,en'olanAbnormal

    Pa+uara

    Pa!Smear

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    Kriotera!i Diagnosa 3 Diagnosa 4

    Po,, Y%

    Po,, Y%

    %asilPeriksa

    I5A

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    DIA(NOSA P

    Diagnosa 6 Diagnosa 7 Diagnosa 8 EK(

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    emeriksaan Penun'ang

    Raiologi Diru'uk  Dara#

    "engka!

    2rin Rutin9

    Mikrosko!ik 

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    er,% re%mme/, +, +%m% %,r

    2015-11-19   YULI NESIYA

    2015-11-19 43271-20-131 3510116805770001   SI"I #$SAEM   1977-05-28

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    %%m% e+/er e /,%+o%1 /,%+o%2 /,%+o%3 /,%+o%4

    '(A)AN 4*3 'ALIBA(U 'UL$N P

    BA(U(E)$ 2*1 'ALIBA(U MANIS   P

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    /,%+o%5 meroo r%+%,%r%+%& m,%o b bb

    2 2 2 2 150 55

    2 2 2 2 150 60

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    ,o /,%o / / %e

    120 80

    120 80

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     o%+%& o,,,v% r,oer%, %me%r em%%,r +oerm%oo+%+/

    1 1   BANYUAN!I

    1 1   BANYUAN!I

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    % eer%%+ eer%+%+ oeeroor,,er,/%

    Me+,% )AA   I("*",/%

    Me+,% )AA   I("*",/%

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    / / %/%r%o e%me% e r%/,oo, /%r%e+

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    r,+r,+ /,r

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