Lampiran

HASIL PEMERIKSAAN MIKROSKOPIK / ENDOSKOPI TELINGA

Nama :
No RM :
Tanggal Lahir :

TELINGA KANAN KIRI

Liang Telinga  Lapang  Destruksi  Lapang  Destruksi
 Sempit  Sempit

Liang Telinga  Serumen  Kolesteatoma  Serumen  Kolesteatoma

 Sekret  Massa/jaringan  Sekret  Massa/jaringan
 Jamur  Benda asing  Jamur  Benda asing:
 Lain-lain: …………..  Lain-lain:
…………
Membran  Intak  Perforasi :  Intak  Perforasi :
timpani o Normal o Sentral o Normal o Sentral
o Hiperemis o Atik o Hiperemis o Atik
o Bulging o Marginal o Bulging o Marginal
o Retraksi o Lain-lain: o Retraksi o Lain-lain:
o Sklerotik ……………….. o Sklerotik …………………..

Kavum  Mukosa : ……………………………………………….  Mukosa : ……………………………………………….

timpani  OsIkel : ……………………………………………….  Osikel : ……………………………………………….
 Isthmus timpani/anterior timpani/posterior  Isthmus timpani/anterior timpani/posterior
timpani : ………………………………………………. timpani :……………………………………………….

Lain-lain ……………………………………………………………………………….. ………………………………………………………………………………..

KESIMPULAN
…………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………

ANJURAN
…………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………

(Kota), ………………………,20….
(……………………………………………………………)