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RS. BHAKTI DARMA HUSADA Surabaya,................................

/2016
Jl. kendung no. 115 – 117 Surabaya
Telp. (031) 7409135
ASSESMENT AWAL PASIEN THT

A. ANAMNESA
Keluhan Utama : ........................................................................................................................... ...........................................................................
Riwayat Penyakit Sekarang :
..................................................................................................................................................... ...................................................................................
............................................................................................................................................................................. ...........................................................
Riwayat Penyakit Dahulu : .......................................................................................................................................................................... .................
Riwayat Penyakit Keluarga: ...................................................................................... ....................................................................................................
Riwayat Pekerjaan: .......................................................................................................... ..............................................................................................
B. PEMERIKSAAN FISIK
Keadaan Umum : ............................................................................................................ .............................................................................................
Kepala/Leher :  Anemis  ikterik  sianosis  dipsnea  Pembesaran KGB  Lain-lain,...............................................................................
Thoraks :  Simetris  Asimetris
- Cor :  Normal  Murmur  Besar  Lain-lain,...............................................................................................................................
- Pulmo :  Normal  Rhonki  Wheezing  Lain-lain,..........................................................................................................................
Abdomen :  Normal  Distensi  Meteorismus  Peristaltik,...................................................................................................................
- Hepar :  Normal  Membesar  Nyeri tekan
- Lien :  Normal  Membesar  Lain-lain,............................................................................................................................ ..............
Ekstremitas :  Normal  Dingin  Edema  Lain-lain,.............................................................................................................................
Genitalia :  Normal  Tidak normal, sebutkan....................................................................................................... ....................................

C. STATUS LOKALIS

Telinga : a. MAE :

b. MT :

Hidung : a. Cavum nasi:

b. Konka :

Tenggorokan : a. Faring :

b. Tonsil :

D. PEMERIKSAAN PENUNJANG
Radiologi :.......................................................................................................... ..................................
Laboratorium : ............................................................................................................................................
Lain-lain :...................................................................................................................................... ......
E. DIAGNOSA SEMENTARA
F. RENCANA TERAPI

Surabaya, .................................. Jam ............

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