STATUS PASIEN

No. MR
:
Tanggal
:
Nama
:
Kelamin
:
Umur
:
DIAGNOSA:

Pekerjaan
Agama
Alamat

:
:
:

1. ANAMNESA
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2. STATUS PRESENS
Sensorium
:
Tek.darah
:
Frekwensi nadi
:

Frekwensi nafas
Suhu tubuh
KU/KP/KG

:
:
:

3. STATUS LOKALISATA
A. TELINGA
DAUN TELINGA KANAN
Bisul
:
Luka
:
Cairan
:
Nyeri tekan
:
Kelainan kongenital
Makroti
:
Mikroti
:
Appendage :
Fistel
:

MEMBRAN TYMPANI: KANAN

Warna

KIRI LIANG TELINGA KANAN

Luas
:
Benjolan
:
Cairan
:
Darah
:
Nanah
:
Serumen
:
Krusta
:
Polip
:
Fistel mastoid
:
Corpus alineum :
Granulasi
:

KIRI
1

KIRI

 Putih mutiara
Hiperemis :
Dof (Suram)
Refleks cahaya
Atrof
:
Bombering/bulging
Perforasi
:
Retraksi
:
Pengapuran
:

:
:
:
:

B. HIDUNG
RHINOSKOPI ANTERIOR
Cavum nasi
:
Selaput lendir :
Permukaan
:
Warna
Konka
:
Inferior
:
Media
Meatus nasi :
Inferior
:
Media
Septum nasi :
Deviasi
Hematoma/abses/perforasi
Nanah
Darah
Krusta
Polip
:
Corpus alienum
:
Massa/tumor

KANAN

KIRI

:
:
:
:
:
:
:

PARANASAL SINUS
Sinus Frontalis
KANAN
KIRI
Nyeri tekan
Transluminasi
RONGGA MULUT
KIRI
A. Bibir
Luka
:
B. Gigi
Karies
:
C. Lidah
Selaput /beslag:
Luka
:
Pergerakan :
D. Palatum mole
warna
:
E. Faring
Selaput
:
Benjolan
:

Sinus Maksillaris
KANAN

TONSIL
Permukaan
Besar
:
Warna
Etter prop
Plica anterior
Kripta
:
Lakuna
Kel.limfe leher :

4. LABORATORIUM
2

KIRI

KANAN
:
:
:
:
:

Darah
Urine

:
:

5. PEMERIKSAAN PENUNJANG

6. RESUME
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7. DIAGNOSA BANDING

8. DIAGNOSA SEMENTARA

9. TERAPI

10. USUL