status pasien tht yang betul

RUMAH SAKIT Dr. H. MARZOEKI MAHDI BOGORSMF ILMU KESEHATAN THT

FAKULTAS KEDOKTERAN TRISAKTI Jl. Dr. Sumeru No.114 Bogor 16111, Telp/Fax. 0251-324025 / 320467 –Pes. 102

STATUS PASIEN THTTanggal :

No. Registrasi :I. IDENTIFIKASI

Nama : Pekerjaan :

Umur : Pendidikan :

Jenis Kelamin : Alamat :

Agama :

Suku Bangsa : Kasus Ke :

Pemeriksa : II. ANAMNESIS

A. Keluhan Utama : ....................................................................................................................

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: ...................................................................................................................

: ...................................................................................................................

Keluhan Tambahan : ...................................................................................................................

: .................................................................................................................:

: .................................................................................................................:

B. Riwayat Penyakit Sekarang : .........................................................................................................

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C. Riwayat Penyakit Dahulu : ............................................................................................................

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D. Riwayat Penyakit Keluarga : .........................................................................................................

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III. PEMERIKSAAN FISIK

A. STATUS GENERALIS

Keadaan umum :

Kesadaran :

Kepala :

Mata :

Leher :Tim DIKLAT RSMM Bogor



Thorax :

Abdomen :

Ekstremitas :

B. STATUS THT

1. PEMERIKSAAN TELINGA

Kanan Kiri

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Daun telinga

Retroaurikuler

Preaurikuler

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LIANG

TELINGA

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a.

b.

c.

d.

e.

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Membran Timpani

Kanan

Pemeriksaan fungsi pendengaranTes Penala 512 Hz

Kiri

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Rinne

Weber

Schwabach

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2. PEMERIKSAAN HIDUNG

Kanan Kiri

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Deformitas

Nyeri tekan

Krepitasi

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Tim DIKLAT RSMM Bogor



RINOSKOPI ANTERIOR

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Vestibulum

Konka inferior

Konka media

Konka superior

meatus nasi

Kavum nasi

Mukosa

Sekret

Seotum

Dasar hidung

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RINOSKOPI POSTERIOR

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Koana

Mukosa konka

Sekret

Muara tuba eustachil

Adenoid

fossa Rusenmuler

Atap nasofaring

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3. PEMERIKSAAN FARING

Arkus Faring :

Pilar anterior :

Palatum molle :

Mukosa faring :

Dinding faring :

Uvula :

Tonsil palatina : Besar :

: Warna :

: Kripta :

: Detritus :

: Perlekatan :

Pilar posterior :

Gigi geligi :

4. HIPOFARING

Basis lidah :

Valekula :

Plika glosospiglotika :

5. PEMERIKSAAN LARING

Epiglotis :

Plika ariepiglotika :




Aritenoid :

Sinus piriformis :

Korda vokalis :

: Pita suara asli

: ...............................................................................

: Pita suara

palsu : ...............................................................................

Subglotik/trakea :

Rima Glotis :

6. LEHER

Pemeriksaan kelenjar getah bening regional :

7. Maksilo Fasial :

IV. RESUME :

V. DIAGNOSA KERJA :

VI. DIAGNOSA BANDING :

VII. RENCANA PENGOBATAN :

VIII. RENCANA PEMERIKSAAN LANJUTAN :

IX. PROGNOSIS :




DOKTER MUDA :

DOKTER PENGAWAS :

TANDA TANGAN :

PENILAIAN :


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