LAPORAN KASUS POLIKLINIK

SENIN 03 JANUARI 2022

Preseptor:
dr. Muslim Kasim, Sp. THT-KL., M.Sc
dr. Bara Ade Wijaya., Sp.THT-KL
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Oleh:
Merryshol Okhi, S.Ked
Mohammad Fajri,S.Ked

KEPANITERAAN KLINIK OTORHINOLARYNGOLOGY

PROGRAM PROFESI DOKTER FAKULTAS KEDOKTERAN
UNIVERSITAS MALAHAYATI RUMAH SAKIT PERTAMINA BINTANG AMIN
BANDAR LAMPUNG
2021
Identitas Pasien S : pasien merasakan telinga kanan nyeri setelah

No RM : 821xx dibersihkan dengan catton bud sejak 3 hari yang lalu,

Nama : Tn. Gusnani
daerah telinga terasa nyeri,berdenging, dan mengalami
Tanggal Lahir : 14-08-1969
penurunan pendengaran
Jenis Kelamin : Perempuan
O:
Umur : 53 tahun

Alamat : Bandar Lampung A: …. Otitis

P:
Identitas Pasien
No RM : 123xxx

Nama :An. Sabrina

Tanggal Lahir : 14-02-2016

Jenis Kelamin : Perempuan

S: telinga kiri terasa ada mainan ,
Umur : 5tahun 10 bulan anak tidak merasakan pusing dan
Alamat : Bandar Lampung demam
O:
A:
P:
Identitas Pasien
No RM : 168xxx
Nama : Tn. Made Wirga
Tanggal Lahir : 22-12-1962
Jenis Kelamin : Laki-laki
Umur : 60 tahun
Alamat : Bandar Lampung
S: telinga kanan masuk air setelah berenang dikolam. Kemudian
telinga kanan dibersihkan dengan catton bud dan merasakan
adanya penurunan pendengaran, bengaka didaerah telinga kanan
serta nyeri. Demam (+), riw. Berobat (-)
O:
A: …. OED + ….
P:
 S: Nyeri tenggorokan dan gatal sejak 2 minggu yang lalu. Jika
Identitas Pasien terkena AC dan kipas angina pasien mengalami batuk. Riw
pengobatan DM+HT
No RM : 354xx

Nama :Ny. Widayanti O:

Tanggal Lahir : 18-10-1963 A:…. Rhinitis alergi

Jenis Kelamin : Perempuan P: ……
Umur : 59 tahun

Alamat : Bandar Lampung

Thank You
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