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    Kasus: Curanmor (Curhat Anda in The Morning) : Nama Mahasiswa: Panjul (0906xxxxxx) Stase E

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    Jody Felizio
    This document contains a case summary from a clinical practice portfolio in ENT (Ear, Nose, and Throat) clinic. It includes the patient's identity, chief complaints, medical history, physical examination findings for the ears, nose, throat and neck. The physical examination was largely normal. The assessment concluded with a primary diagnosis of nothing abnormal and a plan for follow up as needed.

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    Kasus: Curanmor (Curhat Anda in The Morning) : Nama Mahasiswa: Panjul (0906xxxxxx) Stase E

    Uploaded by

    Jody Felizio
    37 views5 pages
    This document contains a case summary from a clinical practice portfolio in ENT (Ear, Nose, and Throat) clinic. It includes the patient's identity, chief complaints, medical history, physical examination findings for the ears, nose, throat and neck. The physical examination was largely normal. The assessment concluded with a primary diagnosis of nothing abnormal and a plan for follow up as needed.

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    portofolio medical

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    BLANKOPORTFOL.docx

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    This document contains a case summary from a clinical practice portfolio in ENT (Ear, Nose, and Throat) clinic. It includes the patient's identity, chief complaints, medical history, physical examination findings for the ears, nose, throat and neck. The physical examination was largely normal. The assessment concluded with a primary diagnosis of nothing abnormal and a plan for follow up as needed.

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    37 views5 pages

    Kasus: Curanmor (Curhat Anda in The Morning) : Nama Mahasiswa: Panjul (0906xxxxxx) Stase E

    Uploaded by

    Jody Felizio
    This document contains a case summary from a clinical practice portfolio in ENT (Ear, Nose, and Throat) clinic. It includes the patient's identity, chief complaints, medical history, physical examination findings for the ears, nose, throat and neck. The physical examination was largely normal. The assessment concluded with a primary diagnosis of nothing abnormal and a plan for follow up as needed.

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    of 5

    Portfolio Modul Praktik Klinik THT Kasus: Curanmor (curhat anda in the morning) Nama Mahasiswa: Panjul (0906xxxxxx)

    Stase E
    Identitas Pasien Nama Pasien Usia / TTL Jenis Kelamin lamat !ama Su"u Pe"e#jaan Status Pe#ni"ahan : : : : : : : :

    Anamnesis dilakukan di Poliklinik Otologi Departemen THT tanggal 12 April 2013, pukul 10.00 WIB se ara autoanamnesis dan alloanamnesis !"i"i pasien#. Keluhan Utama:

    $iwa%at Pen%a"it Se"a#an!:

    $iwa%at Pen%a"it &ahulu:

    $iwa%at Pen%a"it Kelua#!a 'an S(sial:

    Pemeriksaan Fisik 1. Umum Kesa'a#an: "(m)(s mentis Kea'aan umum: *ai" Te"anan 'a#ah: +00/60 mm,! Na'i: -0 "ali / menit. #e!ule#. isi /u"u) Pe#na)asan: 00 "ali / menit. #e!ule# Suhu: 16.0(2 3e#at *a'an: 04 "!

    2. T,T Telinga $anan !AD# 3entu" n(#mal. ti'a" hi)e#emis. ti'a" a'a si"at#i"s. n%e#i te"an t#a!us ti'a" a'a Ti'a" e'ema. ti'a" hi)e#emis. n%e#i te"an mast(i' ti'a" a'a La)an!. ti'a" a'a se"#et. te#'a)at se#umen Pe#5(#asi su*t(tal 'i sent#al. u"u#an 406 'iamete#. hi)e#emis. #e5le"s /aha%a ne!ati5 Telin!a u#i"ula Telinga $iri !A%# 3entu" n(#mal. ti'a" hi)e#emis. ti'a" a'a si"at#i"s. n%e#i te"an t#a!us ti'a" a'a Ti'a" e'ema. ti'a" hi)e#emis. n%e#i te"an mast(i' ti'a" a'a La)an!. ti'a" a'a se"#et. te#'a)at se#umen 7nta". ti'a" hi)e#emis. #e5le"s /aha%a a#ah jam 89-

    $et#(au#i"ula Lian! telin!a

    Mem*#an tim)ani

    7LUST$ S7

    Tes Penala Ne!ati5. 5#e"uensi :+0 ,; Ne!ati5. 5#e"uensi +004 ,; Ne!ati5. 5#e"uensi 004- ,; <e*e# Late#alisasi "e telin!a "anan () Sama 'en!an )eme#i"sa. 5#e"uensi :+0 ,; S/hawa*/h Sama 'en!an )eme#i"sa. 5#e"uensi :+0 ,; $inne P(siti5. 5#e"uensi :+0 ,; P(siti5. 5#e"uensi +004 ,; P(siti5. 5#e"uensi 004- ,;

    Hidung $anan Ti'a" a'a 'e5(#mitas. ti'a" tam)a" tan'a #a'an! La)an! La)an!

    Hidung ,i'un! lua# =esti*ulum nasi Lu*an! hi'un! $(n!!a hi'un!

    Hidung $iri Ti'a" a'a 'e5(#mitas. ti'a" tam)a" tan'a #a'an! La)an! La)an! 7LUST$ S7

    Ti'a" tam)a" 'e>iasi

    Se)tum &asa# hi'un!

    Ti'a" tam)a" 'e>iasi

    Ti'a" tam)a" Eut#(5i Eut#(5i Ti'a" tam)a"

    K(n"a nasalis su)e#i(# K(n"a nasalis me'ia K(n"a nasalis in5e#i(# Meatus nasi su)e#i(#

    Ti'a" tam)a" Eut#(5i Eut#(5i Ti'a" "tam)a"

    Meatus nasi me'ius Meatus nasi in5e#i(# N%e#i te"an (9) N%e#i te"an (9) N%e#i te"an (9) Sinus ma"sila#is Sinus etm(i'alis Sinus 5#(ntalis N%e#i te"an (9) N%e#i te"an (9) N%e#i te"an (9)

    $anan

    Nasofaring K(ana Se)tum 3ela"an! Se"#et K(n"a Mua#a Tu*a Eusta/hius T(#us Tu*a#ius ?(sa $(senmulle# 'en(i' 7LUST$ S7

    $iri

    Laring - Faring 7LUST$ S7 E)i!l(tis Pli"a #ie)i!l(ti"a

    Pita Sua#a Palsu Pita Sua#a Ka#tila!( #iten(i' Su*!l(tis ?(ssa )i#i5(#mis #"us ?a#in! U>ula &in'in! ?a#in! Simet#is &i ten!ah Ti'a" hi)e#emis. ti'a" tam)a" !#anul T+ @ T+. ti'a" hi)e#emis. "#i)ti ti'a" mele*a#. 'et#itus ti'a" a'a. ti'a" a'a )e#len!"etan

    T(nsil

    Pemeriksaan Penun ang 1. Pas 5(t( 'an 5(t(!eni" !" #iagnosis Ker a +A #iagnosis $anding +A %encana Penatalaksanaan (dan indikasi) 1. &i'(a"an )a" "%ai

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