STATUS

OTOLOGI / RINOLOGI / FARINGOLARINGOLOGI

Dokter Muda : Devi Ramadhani

Minggu ke : II

Dokter PPDS : dr. Felicia Melani

Dokter Supervisor : dr. Adlin Adnan, Sp. T.H.T.K.L (K)

DEPARTEMEN / SMF

ILMU KESEHATAN TELINGA HIDUNG TENGGOROKAN

BEDAH KEPALA LEHER

FAKULTAS KEDOKTERAN UNIVERSITAS SUMATERA UTARA

RUMAH SAKIT UMUM PUSAT HAJI ADAM MALIK

MEDAN
 TELINGA HIDUNG TENGGORAKAN BEDAH KEPALA LEHER

FAKULTAS KEDOKTERAN UNIVERSITAS SUMATERA UTARA

RUMAH SAKIT UMUM PUSAT HAJI ADAM MALIK

JALAN BUNGA LAU NO.17 MEDAN

No.MR : Suku :

Tanggal : Agama :

Nama : Alamat :

Kelamin : Dokter Muda :

Umur : Dokter /
Supervisor Pekerjaan : :

DIAGNOSA :

1. Anamnesa

Keluhan Utama
:_______________________________________________

Telaah :_____________________________________________
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RPT :_____________________________________________
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RPO / Alergi
Obat:________________________________________________

KANAN KIRI
TELINGA
Cairan : : ........................................ .............................................
 Darah : ........................................ .............................................
 Nanah : ........................................ .............................................

Sakit : ........................................ .............................................

Bengkak : ........................................ .............................................
Pendengaran : ........................................ .............................................
Dikorek : ........................................ .............................................
Nyeri jika buka : ........................................ .............................................
mulut
Berdengung / : ........................................ .............................................
Tinnitus

KANAN KIRI
HIDUNG
Cairan : : ...................................... ...........................................
 Ingus : ...................................... ...........................................
 Darah : ...................................... ...........................................
 Nanah : ...................................... ...........................................
Berbau : ...................................... ...........................................
Tumpat : ...................................... ...........................................
Sakit : ...................................... ...........................................
Gatal : ...................................... ...........................................
Bersin : ...................................... ...........................................
Penciuman : ..................................... .......................................
Anosmia : ...................................... ........................................
Hiposmia : ...................................... ........................................
 Kakosmia : ..................................... ........................................
Disosmia : ..................................... ........................................
Parosmia : ..................................... ........................................
Phantosmia : ..................................... ........................................
Agnosia : ..................................... ........................................

LEHER :
Benjolan : .....................................................................................
Luka : .....................................................................................
Nanah : .....................................................................................
Fistula : .....................................................................................
Nyeri : .....................................................................................

TENGGOROK :
Sakit Menelan : ..................................................................................
....
Sulit Menelan
 Cair : ..................................................................................
 Padat ....
..................................................................................
....
Sangkut Menelan : ..................................................................................
....
Gatal : ..................................................................................
....
Lendir : ..................................................................................
....
Batuk : ..................................................................................
 Darah ....
 Dahak : ..................................................................................
 Kering : ....
..................................................................................
: ....
..................................................................................
....

Serak / Disfonia : ........................................................................

Sesak / Dispnoe
Rasa PanasPadaTenggorok
Rasa KeringPadaTenggorok
Mengorok / Stridor
Inspiratoar – Ekspiratoar
: ........................................................................
: ........................................................................
: ........................................................................
: ........................................................................

1. ANAMNESIS UMUM
Demam : ..................................................................................
Batuk : ..................................................................................
Pilek : ..................................................................................
Oyong/ Vertigo : ..................................................................................

2. STATUS PRESENS
Sensorium : ............................. Frek.Nafas : .........................
Tekanan Darah : ............................. Temperatur : .........................
Frekuensi Nadi : ............................ KU/KP/KG : .........................

3. STATUS LOKALISATA
TELINGA

DAUN TELINGA KANAN KIRI

Bisul : ...................................... ......................................
Luka : ...................................... ......................................
Cairan : ...................................... ......................................
Nyeri tekan : ...................................... ......................................
Kelainan Kongenital :
 Makrotia : ...................................... ......................................
 Miktrotia : ...................................... ......................................
 Appendage : ...................................... ......................................
 Preurikula : ......................................... .......................................
 Tumor : ....................................... .......................................
 Othematom : ....................................... ......................................

LIANG TELINGA KANAN KIRI

Luas : ........................................ ........................................

Benjolan : ........................................ ........................................
Cairan : ........................................ ........................................
Darah : ........................................ ........................................
Nanah : ........................................ ........................................
Serumen : ........................................ ........................................
Krusta : ........................................ ........................................
Exostosis : ....................................... ........................................
Polip : ........................................ ........................................
Corpus Alienum : ........................................ ........................................
Granulasi : ........................................ .......................................
.
: ........................................ ........................................
RETRO AURICULAR
Massa/ tumor
Abses
Fistula : ………………………… ………………………...
Jaringan bekas operasi : ………………………… …………………………
: ………………………… …………………………

MEMBRAN TIMPANI KANAN KIRI

Warna :
 Putih mutiara : .................................. ..................................
 Hiperemis : .................................. ..................................
 DOF(Suram) : .................................. ..................................
Refleks cahaya : .................................. ..................................
Atrofi : .................................. ..................................
Bombering/Bulging : .................................. ..................................
Perforasi : .................................. ..................................
Retraksi : .................................. ..................................
Pengapuran : .................................. ..................................
Atelektasis : .................................. ..................................

TES PENDENGARAN KANAN KIRI

Berbisik : .................................. ..................................
RinneTest : .................................. ..................................
Weber Test : .................................. ..................................
Scawabach : .................................. ..................................
Bing Test : .................................. .................................

PENALA KANAN KIRI

128 Hz : .................................. ..................................
256 Hz : .................................. ..................................
512 Hz : .................................. ..................................
1024 Hz : .................................. ..................................
2048 Hz : .................................. ..................................

BATANG HIDUNG KANAN KIRI

Bentuk : .................................. ..................................

 Luka : .................................. ..................................
Cairan : .................................. ..................................
Bisul : .................................. ..................................
Fistula : .................................. ..................................

KANAN KIRI
RHINOSKOPI ANTERIOR

Cavum Nasi : ................................ ................................

Selaput Lendir : ................................ ................................
 Permukaan : ................................ ................................
 Warna : ................................ ................................
Konka :
 Inferior : ................................ ................................
 Media : ................................ ................................
Septum Nasi :
 Deviasi : ................................ ................................
 Krista : ................................ ................................
 Spina/Tajam : ................................ ................................
 Hematoma : ................................ ................................
 Abses/Perforasi : ................................ ................................
Nanah : ................................ ................................
Darah : ................................ ................................
Krusta : ................................ ................................
Polip : ................................ ................................
Corpus Alienum : ................................ ................................
Massa/Tumor : ................................ ................................

Gambar Rongga Hidung

RHINOSKOPI POSTERIOR KANAN KIRI

Cavum Nasi : ................................ ................................

Selaput Lendir : ................................ ................................
Septum Nasi : ................................ ................................
Konka :
 Superior : ................................ ................................
 Media : ................................ ................................
Meatus Nasi :
 Superior : ................................ ................................
 Media : ................................ ................................

Tonsilo Pharingeal/Adenoid : ................................ ................................

Epifaring : ................................ ................................
Tuba Wall : ................................ ................................
Fossa Rossenmuller : ................................ ................................
Massa/Tumor : ................................ ................................
Posterior Nasal Drip : ................................ ................................

PARANASAL SINUS

Sinus Frontalis Sinus Maksilaris

KANAN KIRI KANAN KIRI
Nyeri Tekan : ................... ................... ................... ...................
Nyeri Perkusi : ................... .................. .................. ...................
Transiluminasi : ................... ................... ................... ...................

RONGGA MULUT

A. Bibir
 Bentuk : ........................................................................
 Luka : ........................................................................
 Fissura/Pecah : ........................................................................
B. Gigi
 Karies : ........................................................................
C. Lidah
 Bentuk : ........................................................................
 Selaput Membran : ........................................................................
 Luka / Ulkus : ........................................................................
 Pergerakan : ........................................................................
D. Pallatum Molle
 Bentuk : ........................................................................
 Warna : ........................................................................
 Uvula : .......................................................................
 Gerakan : .......................................................................

E.Faring
 SelaputLendir : ........................................................................
 Luka : ........................................................................
 Selaput .......................................................................
 Benjolan : ........................................................................
 .....

F. TONSIL KANAN KIRI

Permukaan : ....................................... .......................................
Besar : ....................................... .......................................
Warna : ....................................... .......................................
Selaput/Membran : ....................................... .......................................
Detritus : ....................................... .......................................
Sikatriks : ....................................... .......................................
Plica Anterior : ....................................... .......................................
Plica Posterior ....................................... .......................................
Perlengketan : ....................................... .......................................
Kripta : ....................................... .......................................
Abses : ....................................... .......................................
Lakuna : ....................................... .......................................
Corpus Alienum : ....................................... .......................................

LARINGOSKOPI INDIREK

Pangkal Lidah : ...................................................................

...
Tonsil Lidah : ...................................................................
...
Papil lidah : ...................................................................
...
Valecula : ...................................................................
...
Epiglotis
 Bentuk : ...................................................................
 Warna : ...
 Lain-lain : ...................................................................
...
...................................................................
...
Lig.Ventrikulare / : ...................................................................
Pita SuaraPalsu ...
LigamentumVocale / Kanan Kiri
Pita SuaraAsli : ...................................................................
 Bentuk : ...
 Warna : ...................................................................
 Luka / Sikatrik : ...
 Selaput/Membran : ...................................................................
 Benjolan / Nodul : ...
 Gerakan : ...................................................................
Simetris / Asimetris. ...
...................................................................
...
...................................................................
...
...................................................................
...

Sinus Piriformis : ...................................................................

.....
Stase Ludah : ...................................................................
......
Trakea
 Benjolan / Massa / : ...................................................................
Corpus Alienum .....

PALPASI LEHER

Benjolan
 Jumlah : ..............................................................................
 Ukuran : ..............................................................................
 Warna : ..............................................................................
 Permukaan : ..............................................................................
 Nyeri Tekan : ..............................................................................
 Mobilitas : ..............................................................................
 Luka : .............................................................................
Fistula : .............................................................................

1. PEMERIKSAAN PENUNJANG

 Audiometri : ........................................................................
 Rontgen : ........................................................................
 CT-Scan : ........................................................................
 Histopatologi : ........................................................................
 Laboratorium
o Darah Lengkap : ........................................................................
 Sniffin Test : ........................................................................
 Skin Prick Test : ........................................................................

2. RESUME / KESIMPULAN

3. GAMBAR
7. DIAGNOSA BANDING

8. DIAGNOSIS SEMENTARA

9. TERAPI/RESEP

10. USUL / SARAN PEMERIKSAAN

11. EDUKASI