BAGIAN ILMU PENYAKIT THT-KL

FAKULTAS KEDOKTERAN UNIVERSITAS HALU OLEO

KENDARI

STATUS PENDERITA

NAMA : AGAMA :
UMUR : PEKERJAAN :
JENIS KELAMIN : STATUS PERKAWINAN :
ANAMNESIS TGL :

KELUHAN UTAMA : ________________________________________________________

ANAMNESIS TERPIMPIN: ________________________________________________________
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PEMERIKSAAN TELINGA:
KANAN KIRI
1. Daun Telinga
Bentuk : ____________________ ____________________
Ukuran : ____________________ ____________________
Sikatriks : ____________________ ____________________
Infeksi : ____________________ ____________________
Tumor : ____________________ ____________________
2. Depan Telinga
Abses / Fistel : ____________________ ____________________
Sikatriks : ____________________ ____________________
Nyeri Tekan Tragus: ____________________ ____________________
3. Belakang Telinga
Abses / Fistel : ____________________ ____________________
Nyeri Tekan : ____________________ ____________________
Tumor : ____________________ ____________________
4. Liang Telinga Luar
Warna : ____________________ ____________________
Edema : ____________________ ____________________
Sekret (Sifat) : ____________________ ____________________
Serumen : ____________________ ____________________
5. Selaput Gendang
Permukaan : ____________________ ____________________
Warna : ____________________ ____________________
Perforasi : ____________________ ____________________
Pantulan Cahaya : ____________________ ____________________
6. Telinga Tengah (Bila ada perforasi)
Mukosa : ____________________ ____________________
Promontorium : ____________________ ____________________
Sekret (Sifat) : ____________________ ____________________

PEMERIKSAAN HIDUNG
KANAN KIRI
1. Bagian Luar Hidung
Bentuk : ____________________ ____________________
Kelainan Kulit : ____________________ ____________________
Kolumella : ____________________ ____________________
Nares Anterior : ____________________ ____________________
Fossa Kanina : ____________________ ____________________
Dinding Media : ____________________ ____________________
2. Bagian Dalam Hidung
Festibulum : ____________________ ____________________
Dasar Rongga Hidung: ___________________ ____________________
o Sekret : ____________________ ____________________
o Edema/Polip : ____________________ ____________________

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3. Dinding Lateral
Meatus Nasi Inferior: ____________________ ____________________
o Polip : ____________________ ____________________
o Edema : ____________________ ____________________
o Sekret : ____________________ ____________________
Konka Inferior : ____________________ ____________________
o Warna : ____________________ ____________________
o Sekret (Sifat) : ____________________ ____________________
o Permukaan : ____________________ ____________________
o Ukuran : ____________________ ____________________
Meatus Nasi Media : ____________________ ____________________
o Polip : ____________________ ____________________
o Edema : ____________________ ____________________
o Sekret(Sifat) : ____________________ ____________________
Konka Media : ____________________ ____________________
o Warna : ____________________ ____________________
o Sekret (Sifat) : ____________________ ____________________
o Permukaan : ____________________ ____________________
o Ukuran : ____________________ ____________________
4. Dinding Media Rongga Hidung
Warna : _______________________________________
Permukaan(Deviasi) : _______________________________________
Edema(Hipertropi) : _______________________________________
Eksoriasi : _______________________________________
Perforasi : _______________________________________
5. Dinding Belakang (Rhinoskopi Posterior)
Koana : _______________________________________
Palatum Molle : _______________________________________
Ujung Post. Konka Inf.: _____________________________________
Ujung Post. Konka Media: ___________________________________
Meatus Nasi Media : _______________________________________
Ostium Tuba : _______________________________________
Torus Tubarius : _______________________________________

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 Fossa Rossen Muller: _______________________________________
Tonsila Tubaria : _______________________________________
Adenoid : _______________________________________
6. Sinus Paranasalis
Transluminasi : _______________________________________

PEMERIKSAAN GIGI, MULUT, KERONGKONGAN, TENGGOROKAN

1. Gigi
Karies : _______________________________________
Abses : _______________________________________
Gusi : _______________________________________
2. Mulut
Abses/Fistel : _______________________________________
Sikatriks : _______________________________________
Nyeri Tekan : _______________________________________
3. Kerongkongan
Orofaring : _______________________________________
o Dinding Dorsal :
KANAN KIRI
Mukosa : ____________________ ____________________
Granula : ____________________ ____________________
Deformitas : ____________________ ____________________
Post Nasal Drips _________________ ____________________
o Dinding Lateral :
Lateral Band: ____________________ ____________________
Deformitas : ____________________ ____________________
Iscum Faucium : ____________________ ____________________
Arkus Anterior : ____________________ ____________________
Arkus Posterior : ____________________ ____________________
Tonsil :
o Warna : ____________________ ____________________
o Pembesaran : ____________________ ____________________
o Detritus : ____________________ ____________________

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 o Kripte : ____________________ ____________________
Perlengketan : ____________________ ____________________
Hipofaring :
Fossa Piriformis: _______________________________________
Vallekula : _______________________________________
Radikal Lingua : _______________________________________
4. Tenggorokan
Epiglotis : _______________________________________
Aritenoid : _______________________________________
Plika Vokalis : _______________________________________
Subglotis : _______________________________________
Trakea : _______________________________________
Kelainan Motorik : _______________________________________
5. Kelenjar Limfe Regional : _______________________________________
6. Kelainan Lain : _______________________________________

PEMERIKSAAN LABORATORIUM:
1. Darah : _______________________________________
2. Urine : _______________________________________
3. Bakteriologis : _______________________________________
4. Dan Lain Lain : _______________________________________

FOTO THORAX : _________________________________________________________________

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 RESUME
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PEMERIKSAAN FISIK
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DIAGNOSA
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DIAGNOSA BANDING
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PENGOBATAN
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ANJURAN
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PROGNOSIS
Quo at vitam : __________________________________________________________________________
Quo at sanationam : _________________________________________________________________________

Nama Dokter Muda : _____________________________________

NIM : _____________________________________

Kendari, 20
Pembimbing,

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