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Form 5
Early Postoperative Findings (Day 2-28)
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Nama pasien
No Medical Record
Date of birth
MM
/
DD
/
YYYY
Address
Date of control
MM
/
DD
/
YYYY
Date of operation
MM
/
DD
/
YYYY
Operated ear ?
Clear selection
Revision surgery ?
Clear selection
Number of previous middle ear surgery ?
Persistent bleeding and/or cerebrospinal fluid liquorrhea ?
Clear selection
Facial nerve function ?
Clear selection
House-Brackmann grade of facial nerve paralysis ?
Clear selection
Taste of anterior tongue of operative side ?
Clear selection
Sense of hearing ability compare to pre operative state ? after all ear canal packing is removed
Clear selection
Tinnitus ?
Clear selection
Tinnitus tone ?
Clear selection
Tinnitus severity ?
Clear selection
Weber test ?
Clear selection
Vestibular function, vertigo / dizziness?
Clear selection
Vestibular function, postural test (Romberg)
Clear selection
Vestibular function, spontaneous nystagmus ?
Clear selection
Vestibular function, positional nystagmus ?
Clear selection
Vestibular function, positioning nystagmus ?
Clear selection
Vestibular function, Fistula test ?
Clear selection
Wound infection ?
Clear selection
Discharge ?
Clear selection
Tympanic membrane ?
Clear selection
Wound healing (squamous epithelization) ?
Clear selection
Chronic respiratory tract disease ?
Clear selection
Systemic disease ?
Clear selection
Microbiology, specimen taken from ?
Clear selection
Microbiology bacteria, aerobes ?
Clear selection
Microbiology bacteria, anaerobes ?
Clear selection
Microbiology, fungi ?
Clear selection
Other bacteria found ?
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