1.

KETERANGAN UMUM
Nama

: ________________________________________

Umur

: ________________________________________

Jenis Kelamin

: ________________________________________

Alamat

: ________________________________________

Agama

: ________________________________________

Pekerjaan

: ________________________________________

Pendidikan

: ________________________________________

Tgl.Pemeriksaan

: ________________________________________

2. ANAMNESIS
Keluhan Utama

: ________________________________________

Anamnesis Khusus

: __________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
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3. PEMERIKSAAN FISIK
Status Generalis
Keadaan Umum
Kesadaran

: _________________________

Kesan sakit

: _________________________

Tensi

: _____ mmHg

Nadi

: _____ menit

Respirasi

: _____ menit

Suhu

: _____ 0C

Kepala

: Conjungtiva
Sclera

Leher

: __________________________

Toraks

: __________________________

Cor

: __________________________

Pulmo

: __________________________

Abdomen

: __________________________

Ekstremitas

: __________________________

Neurologis

: __________________________

Status Lokalis
Telinga
Bagian

Kelainan

Preaurikula

Kelainan kongenital
Radang dan tumor
Trauma

Aurikula

Kelainan kongenital
Radang dan tumor
Trauma

Retroaurikula

Edema
Hiperemis
Nyeri tekan
Sikatriks
Fistula
Fluktuasi

Auris
Dextra

Sinistra

Kelainan kongenital
Kulit
Sekret
Canalis Acustikus
Serumen
Externa
Edema
Massa
Cholesteatoma
Warna
Intak
Reflek cahaya
Membrana
Timpani

Hidung
Bentuk dan Ukuran
Mukosa
Sekret
Concha
Septum
Polip/tumor
Pasase udara

Dekstra

Sinistra

Mulut Dan Orofaring

Mukosa
Gigi-geligi
Tonsil
Pharynx

Tenang

RESUME :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

IV.

DIAGNOSIS BANDING :

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
V. USULAN PEMERIKSAAN :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
VI.

DIAGNOSIS KERJA :

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
4. PENATALAKSANAAN :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
5. PROGNOSIS
Quo ad vitam

: _______________________

Quo ad functionam

: _______________________
5

STATUS PASIEN
POLIKLINIK/RUANGAN

Nama

: .

NPM

: .

Jenis Status

: .

PROGRAM PENDIDIKAN PROFESI DOKTER

BAGIAN TELINGA HIDUNG TENGGOROKAN-KEPALA LEHER
FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM BANDUNG
2013