BAGIAN/SMF ILMU PENYAKIT THT

FAKUTAS KEDOKTERAN UNLAM/RSUD ULIN BANJARMASIN

STATUS DOKTER MUDA

KEPANITERAAN KLINIK
Nama Mahasiswa : NIM :
Tanggal : Tanda Tangan :
STATUS PENDERITA
I. IDENTITAS
NAMA : SUKU :
UMUR : ALAMAT :
JENIS KELAMIN :
PEKERJAAN : RMK :

II. ANAMNESA
TANGGAL :…………………………………………………………………………………...
KELUHAN UTAMA :……………………………………………………………………………….......
RIWAYAT PENYAKIT :…………………………………………………………………………................
SEKARANG .................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
RIWAYAT PENYAKIT :…………………………………………………………………………................
DAHULU .................................................................................................................................
.................................................................................................................................
RIWAYAT PENYAKIT :................................................................................................................................
KELUARGA .................................................................................................................................
RIWAYAT :................................................................................................................................
PENGOBATAN .................................................................................................................................
RIWAYAT :................................................................................................................................
KEBIASAAN .................................................................................................................................

III. PEMERIKSAAN FISIK

1. STATUS GENERALIS
KEADAAN UMUM : KESADARAN:
TANDA VITAL :

2. STATUS LOKALIS
A. TELINGA
Inspeksi

Palpasi

MAE

MT

Test Pendengaran
 B. HIDUNG
Inspeksi

Palpasi

R.A. RP.

TRANLUMINASI
S.P. S.M.

C. TENGGOROK
Rongga Mulut

Orofaring

Laring

D. LEHER
Kelenjar Getah Bening

IV. DIAGNOSIS

V. PEMERIKSAAN PENUNJANG

VI. TATALAKSANA