RSPAD GATOT SOEBROTO

DEPARTEMEN THT

STATUS PENDERITA

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

1. KELUHAN UTAMA :
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2. Riwayat Penyakit Sekarang :

(Meliputi : Onset, Intensitas, Faktor memperingan/memperberat, Keluhan
Tambahan, Riwayat Pengobatan)
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3. Riwayat Penyakit Dahulu :

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4. Riwayat Penyakit Keluarga :

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5. Faktor Ekonomi/kebiasaan :
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Pemeriksaan Fisik Umum
1. Status Generalis
KeadaanUmum :
Kesadaran :
Skala Nyeri :

Tanda Vital :
- TekananDarah = mmHg - Respiras = x/menit
i
- Nadi = x/menit - Suhu = °C

Kepala :

Leher :

Thorax :

Abdomen :

Ekstremitas :

Neurologis :

2. Status Lokalis :
PEMERIKSAAN TELINGA :
KANAN KIRI

1. DaunTelinga
 Bentuk : _______________ _______________
 Ukuran : _______________ _______________
 Sikatriks : _______________ _______________
 Infeksi : _______________ _______________
 Tumor : _______________ _______________

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2. DepanTelinga
 Abses / Fistel : _______________ _______________
 Sikatriks : _______________ _______________
 Nyeri Tekan Tragus : _______________ _______________
3. Belakang Telinga
 Abses / Fistel : _______________ _______________
 NyeriTekan : _______________ _______________
 Tumor : _______________ _______________
4. Liang TelingaLuar
 Warna : _______________ _______________
 Edema : _______________ _______________
 Sekret (Sifat) : _______________ _______________
 Serumen : _______________ _______________
5. Selaput Gendang
 Permukaan : _______________ _______________
 Warna : _______________ _______________
 Perforasi : _______________ _______________
 PantulanCahaya : _______________ _______________

6. Telinga Tengah (Bila ada perforasi)

 Mukosa : _______________ _______________
 Promontorium : _______________ _______________
 Sekret (Sifat) : _______________ _______________

PEMERIKSAAN HIDUNG :
KANAN KIRI

1. BagianLuarHidung
 Bentuk : _______________ _______________
 KelainanKulit : _______________ _______________

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  Kolumella : _______________ _______________
 Nares Anterior : _______________ _______________
 Fossa Kanina : _______________ _______________
 Dinding Media : _______________ _______________

2. Bagian Dalam Hidung

 Vestibulum : _______________ _______________
 Dasar Rongga Hidung
- Sekret : _______________ _______________
- Edema / Polip : _______________ _______________

3. Dinding Lateral
 Meatus Nasi Inferior
- Polip/tumor : _______________ _______________
- Edema : _______________ _______________
- Pasase Udara : _______________ _______________
- Sekret : _______________ _______________
 Konka Inferior
- Warna : _______________ _______________
- Sekret (Sifat) : _______________ _______________
- Permukaan : _______________ _______________
- Ukuran : _______________ _______________
 Meatus Nasi Media
- Edema : _______________ _______________
- Sekret (Sifat) : _______________ _______________
- Polip : _______________ _______________

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  Konka Media
- Permukaan : _______________ _______________
- Warna : _______________ _______________
- Sekret : _______________ _______________
- Ukuran : _______________ _______________

4. Dinding Media RonggaHidung

 Warna :
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 Permukaan(Deviasi):
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 Edema (Hipertrofi) : __________________________
 Eksoriasi : __________________________
 Perforasi : __________________________

5. DindingBelakang (Rhinoskopi Posterior)

 Koana :__________________________

 Palatum Molle : _________________________

 Nasofaring : __________________________
 Ostium Tuba : __________________________
 Torus Tubarius : __________________________
 Fossa Rossenmuller:__________________________
 Adenoid : __________________________

6. Sinus Paranasalis
 Transiluminasi : __________________________
 Tanda radang : Normal/kemerahan/pembengkakan
 Nyeri Spontan : - / + / + (etmoid/frontal/maxilla)
 Nyeri tekan : - / + / + (etmoid/frontal/maxilla)
 Nyeri alih :-

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PEMERIKSAAN GIGI, MULUT, KERONGKONGAN, TENGGOROKAN :
1. Gigi
 Karies : __________________________
 Abses : __________________________
 Gusi : __________________________

2. Mulut
 Abses / Fistel : __________________________
 Sikatriks : __________________________
 NyeriTekan : __________________________

3. Kerongkongan
 Orofaring
- Dinding Dorsal
1. Mukosa : _______________ _______________
2. Granula : _______________ _______________
3. Deformitas : _______________ _______________
4. Post Nasal Drips ______________ _______________
- Dinding Lateral
1. Lateral Band : _______________ _______________
2. Deformitas : _______________ _______________
 IsmusFaucium : _______________ _______________
 Arkus Anterior : _______________ _______________
 Arkus Posterior : _______________ _______________
 Tonsil
- Warna : _______________ _______________
- Pembesaran : _______________ _______________
- Detritus : _______________ _______________
- Kripte : _______________ _______________
- Perlengketan : _______________ _______________
 Hipofaring
- Fossa Piriformis : __________________________
- Vallekula : __________________________
- Radikal Lingua : __________________________

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4. Tenggorokan
 Epiglotis : __________________________
 Aritenoid : __________________________
 PlikaVokalis : __________________________
 Subglotis : __________________________
 Trakea : __________________________
 KelainanMotorik : __________________________

KEPALA DAN LEHER

5. KelenjarLimfe
 Lokasi :
Submandibula/Submental/Anterior/Posterior
Sternocledomastoideus/Supraclavicula
 Melekat/bebas
 Permukaan : rata/berbenjol
 Trismus :

6. PemeriksaanSaraf :
NI : N VII :
N II : N VIII :
N III, IV, VI : N IX :
NV : N XI :
NX :
N XII :

PEMERIKSAAN PENUNJANG
1. Darah :
Hb : ______________________
Leukosit : __________________
Trombosit : _________________
Waktu Perdarahan/Pembekuan : ____________________

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2. Urine : __________________________
3. Bakteriologis : __________________________
4. Patologi anatomi : __________________________

FOTO THORAX :
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RESUME
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DIAGNOSA KERJA
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DIAGNOSA BANDING
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PENATALAKSANAAN
1. Umum
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2. Medikamentosa
A. Lokal :
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B. Sistemik :
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USULAN &RENCANA KERJA

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PROGNOSIS
 Quo at vitam ___________________________________________________
 Quo at Functionam _________________________________________________
 Quo at sanationam

Nama Mahasiswa :____________________________________________________

NIM :____________________________________________________
TanggalUjian : ____________________________________________________
Nilai :

Jakarta,
TTD Pembimbing

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