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LAPORAN KASUS POLI
THT-KL
Kepaniteraan Klinik SMF Ilmu Otorhinolaryngology
Fakultas Kedokteran Universitas Malahayati
Rumah Sakit Pertamina Bintang Amin
Bandar Lampung
2023
P r e s e p t o r :
dr. Muslim Kasim, M.Sc, Sp. THT-KL
Jumat, 17 April 2023
O l e h :
A h m a d A n s o r i
P u t r i f e b r i a n a
S o n i a
F e r d i n a n A . P
Nama : Ny. F
No. RM : 491xx
Tanggal Lahir : 20-04-1960
Jenis Kelamin : Perempuan
Alamat : Bandar Lampung
Pasien mengeluhkan telinga kanan
berdenging sejak 3 mgg yg lalu nyeri(-),
demam(-)
TD 190/100mmhg
s
O P
A
Identitas Pasien
 Otitis Media Eksterna
 NaCl 0,9%
 MP
Nama : An. H
No. RM : 1865xx
Jenis Kelamin : Laki-laki
Tanggal Lahir : 10-08-2014
Alamat : Bandar Lampung
Pasien mengeluh nyeri telan kurang lebih
1 bln, sertai demam hilang timbul sejak 2
mgg yll
BB 49,8kg
s
O
P
A
Identitas Pasien
 Tonsilitis
 Cefixim 100mg
 Tremenza ½ tab
 Ambroxol 2x1 tab
 PCT 500mg
Nama : Ny. M
No. RM : 1829xx
Tanggal Lahir : 13-11-1928
Jenis Kelamin : Perempuan
Alamat : Bandar Lampung
telinga kanan berdenging setelah
kemasukkan air sejak 2 hari yg lalu.
demam (-), nyeri (-), penurunan
pendengaran (-)
TD 130/80
s
O
P
A
Identitas Pasien
 OED
Nama : Tn. B
No. RM : 1879xx
Jenis Kelamin : Laki-laki
Tanggal Lahir : 10-01-1970
Alamat : Bandar Lampung
Leher sebelah kanan saat menelan sakit
ada tahanan 4 minggu yg lalu
TD120/70
s
O
P
A
Identitas Pasien
 LPR
 omeprazol
 Ambroxol 2x1 tab
Nama : Ny. P
No. RM : 1842xx
Tanggal Lahir : 21-09-1988
Jenis Kelamin : Perempuan
Alamat : Bandar Lampung
Pasien datang kontrol hidung keluar
cairan. Kadang terasa nyeri di sekitar
pelipis dan hidung rasanya lengket
seperti ada darah yang belum keluar
TD: 140/90
s
O P
A
Identitas Pasien
 RSK
 NaCl 0,9%
 Tremenza ½ tab
 Ambroxol 2x1 tab
Nama : Ny. M
No. RM : 1860xx
Tanggal Lahir : 04-07-1985
Jenis Kelamin : Laki-laki
Alamat : Bandar Lampung
Pasien datang dengan keluhan telinga
sebelah kanan berdengung sejak 4 tahun
lalu. Pendengaran agak terganggu. Nyeri
(-), keluar cairan (-), pusing berputar (-)
TD: 120/80
s
O P
A
Identitas Pasien
 Ad/S OMSK
 Ciprofloxacin 500mg
 Tremenza 2x1 tab
 Ambroxol 2x1 tab
Nama : An. B
No. RM : 1879xx
Tanggal Lahir : 04-07-1985
Jenis Kelamin : Perempuan
Alamat : Bandar Lampung
Pasien datang dengan keluhan telinga
sebelah kanan berdengung sejak 4 tahun
lalu. Pendengaran agak terganggu. Nyeri
(-), keluar cairan (-), pusing berputar (-)
BB: 14 kg
s
O P
A
Identitas Pasien

 NaCl 0,9%
 Tremenza ½ tab
 Ambroxol 2x1 tab
TERIMA KASIH

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Laporan Jaga Poli THT (senin 17 april ).pptx

  • 1. LAPORAN KASUS POLI THT-KL Kepaniteraan Klinik SMF Ilmu Otorhinolaryngology Fakultas Kedokteran Universitas Malahayati Rumah Sakit Pertamina Bintang Amin Bandar Lampung 2023 P r e s e p t o r : dr. Muslim Kasim, M.Sc, Sp. THT-KL Jumat, 17 April 2023 O l e h : A h m a d A n s o r i P u t r i f e b r i a n a S o n i a F e r d i n a n A . P
  • 2. Nama : Ny. F No. RM : 491xx Tanggal Lahir : 20-04-1960 Jenis Kelamin : Perempuan Alamat : Bandar Lampung Pasien mengeluhkan telinga kanan berdenging sejak 3 mgg yg lalu nyeri(-), demam(-) TD 190/100mmhg s O P A Identitas Pasien  Otitis Media Eksterna  NaCl 0,9%  MP
  • 3.
  • 4. Nama : An. H No. RM : 1865xx Jenis Kelamin : Laki-laki Tanggal Lahir : 10-08-2014 Alamat : Bandar Lampung Pasien mengeluh nyeri telan kurang lebih 1 bln, sertai demam hilang timbul sejak 2 mgg yll BB 49,8kg s O P A Identitas Pasien  Tonsilitis  Cefixim 100mg  Tremenza ½ tab  Ambroxol 2x1 tab  PCT 500mg
  • 5.
  • 6. Nama : Ny. M No. RM : 1829xx Tanggal Lahir : 13-11-1928 Jenis Kelamin : Perempuan Alamat : Bandar Lampung telinga kanan berdenging setelah kemasukkan air sejak 2 hari yg lalu. demam (-), nyeri (-), penurunan pendengaran (-) TD 130/80 s O P A Identitas Pasien  OED
  • 7.
  • 8. Nama : Tn. B No. RM : 1879xx Jenis Kelamin : Laki-laki Tanggal Lahir : 10-01-1970 Alamat : Bandar Lampung Leher sebelah kanan saat menelan sakit ada tahanan 4 minggu yg lalu TD120/70 s O P A Identitas Pasien  LPR  omeprazol  Ambroxol 2x1 tab
  • 9.
  • 10. Nama : Ny. P No. RM : 1842xx Tanggal Lahir : 21-09-1988 Jenis Kelamin : Perempuan Alamat : Bandar Lampung Pasien datang kontrol hidung keluar cairan. Kadang terasa nyeri di sekitar pelipis dan hidung rasanya lengket seperti ada darah yang belum keluar TD: 140/90 s O P A Identitas Pasien  RSK  NaCl 0,9%  Tremenza ½ tab  Ambroxol 2x1 tab
  • 11.
  • 12. Nama : Ny. M No. RM : 1860xx Tanggal Lahir : 04-07-1985 Jenis Kelamin : Laki-laki Alamat : Bandar Lampung Pasien datang dengan keluhan telinga sebelah kanan berdengung sejak 4 tahun lalu. Pendengaran agak terganggu. Nyeri (-), keluar cairan (-), pusing berputar (-) TD: 120/80 s O P A Identitas Pasien  Ad/S OMSK  Ciprofloxacin 500mg  Tremenza 2x1 tab  Ambroxol 2x1 tab
  • 13.
  • 14. Nama : An. B No. RM : 1879xx Tanggal Lahir : 04-07-1985 Jenis Kelamin : Perempuan Alamat : Bandar Lampung Pasien datang dengan keluhan telinga sebelah kanan berdengung sejak 4 tahun lalu. Pendengaran agak terganggu. Nyeri (-), keluar cairan (-), pusing berputar (-) BB: 14 kg s O P A Identitas Pasien   NaCl 0,9%  Tremenza ½ tab  Ambroxol 2x1 tab
  • 15.