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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