RM

RS ISLAM MALAHAYATI MEDAN

Nama

ILMU PENYAKIT THT

Ruangan :

Tgl.Lahir :
No RM

Tgl

L/P
Jam :

: Ya dari
RS ...............................................
.Puskesmas ...................................................
Dr. ...............................................

Lainnya ........................................................
Dx Rujukan ..............................................................................................................................
Tidak Datang Sendiri
Diantar...........................................................
Nama Keluarga yang bisa dihubungi:..................................................No.HP/Telp:.........................................................................
Alamat
:................................................................................................................................................
Transportasi waktu datang
: Ambulans RS Islam Malahayati
Ambulans Lain................. . Kend. Lainnya................
ALERGI TERHADAP:
Rujukan

Penilaian Nyeri
Nyeri : ( ) tidak, ( ) ya:

lokasi: ______________ Intensitas (0-10):_____

Jenis : akut ( ), kronis ( )

Tanda tangan Dokter

Dokter yang memeriksa:..............................................................................
ANAMNESA
1. Keluhan Utama: ..................................................................................................................................................................
2. Keluhan tambahan
HIDUNG
Kanan
Kiri
TENGGOROK
TELINGA
Kanan Kiri
Sekret
.......... ........ Sekret
.......... .........
Riak
: ...............................
Tuli
.......... ........ Tersumbat
.......... .........
Gangguan
: ...............................
Tumor
.......... ......... Tumor
.......... .........
Suara
: ...............................
Tinitus
.......... ........ Pilek
.......... .........
Tumor
: ...............................
Sakit
.......... ........ Sakit
.......... .........
Batuk
: ...............................
Korpus Alienum
.......... ......... Korpus Alienum
.......... .........
Korpus Alienum : ...............................
Vertigo
.......... ........
Bersin
.......... .........
Sesak Nafas
: ...............................
PEMERIKSAAN FISIK
1. Status Internus
Keadaan Umum:...................Tek. Darah:...........mmHg Nadi:..........X/menit Respirasi:..........X/menit Suhu:........ oC
Cor
: .........................................................................................................................................................................
Pulmo
: .........................................................................................................................................................................
Hepar/Lien: .........................................................................................................................................................................
2. Status THT
TELINGA
Kanan
Kiri
HIDUNG
Kanan
Kiri
Daun telinga
: ................................ .........................
Hidung Luar : .......................................... .........................
Liang telinga
: ................................ .........................
Kavum nasi : .......................................... .........................
Discharge
: ................................ .........................
Septum
: .......................................... .........................
Membrana Timpani: ................................ .........................
Discharge : .......................................... .........................
Tumor
: ................................ .........................
Mukosa
: .......................................... .........................
Mastoid
: ................................ .........................
Tumor
: .......................................... .........................
Tes pendengaran :
Konka
: .......................................... .........................
Berbisik
: ................................ .........................
Sinus
: .......................................... .........................
Weber
: ................................. .........................
Koana
: .......................................... .........................
Rinne
: ................................. .........................
Naso Endoskopi : ................................... .........................
TENGGOROK
Schwabach
: ................................ .........................
Dispenu : ....................
Stridor: ...............................
BOA
: ................................ .........................
Sianosis : ....................
Suara : ...............................
Tympanometri: ................................ ..........................
Mucosa : .....................
Tonsil : ...............................
Audiometri
Nada Murni : ................................ .........................
Dinding belakang: ...............................................................
BERA
: ................................ ..........................
LARING
OAE
: ................................ ...........................

Epiglotis
:
........................
Plika Vokalis: .....................
Tes Alat
Aritenoid: ........................
Rimaglotis : ......................
Keseimbangan: ................................ ..........................
Plika Ventrikuloris: ...............................................................
Endoskopi:.............................................................................
DIAGNOSA KERJA/DIAGNOSA BANDING
Kelenjar limpe leher:
TERAPI
DISPOSISI
Kontrol: Ya
Tanggal:.................................. Tidak
Dirawat: Ruang:............................. Kelas:.................................

DiReview oleh dokter yang merawat di Rawat Inap

Medan, Tgl

Tanda Tangan dan Nama Dokter