F INAL E XAM C ASE P RESENTATION

EAR NOSE THROAT - HEAD AND NECK DEPARTMENT

R. SYAMSUDIN, SH HOSPITAL, SUKABUMI

Examiner :
dr. H. Oscar Djauhari, Sp. THT
Presented by :
Zaras Yudisrhira Saga 2008730133

Clinical Rotation
Medical Faculty of Muhammadiyah Jakarta University
Syamsudin, S.H. Regional General Hospital, Sukabumi
Period November 19th 2012 Desember 22th 2012

Final Exam Case Presentation

a. Identity

R. SYAMSUDIN, SH HOSPITAL
EAR NOSE THROAT - HEAD AND NECK DEPARTMENT
Anthony (2010-061-136)
Mentor : dr. H. Oscar Djauhari , Sp. THT
Name
Age
Sex
Occupation
Address
Race

: Mr. F
: 8 years old
: Male
: Student
: Rawa Bungur RT 3/rw 6 Sindang Sari Lembur Situ Sukabumi
: Sundanese

b. Anamnesa:
Chief complaint
Additional complaint

: Earache from right ear since 1 day ago

: Nasal blockage in both nose, facial pain , decrease of
smell

History of Illness :
Patient came to ENT clinic R.Syamsudin, SH hospital with chief complain of
earache from right ear since 1 day ago. At first the discharge was initially clear and
watery, but later it became greenish and purulent. Her parents complaint the smell of her
discharge was foul odor. The patient also felt blockade from both of her nose and difficult
in breathing.
One week before came to the hospital, she felt pain in her face , between her
eye. She also felt diificulty in smelling anything, for example food. She didn't have any
cough or fever accompany these complaints. She didnt have dental pain, ear pain,
sensation of fullness in the ear, or sore troat.
History of Past Illness:
History of similar illnes in the past (-)
History of allergic (-)
History of Asthma (-)
c. Physical Examination
Consciousness
: Compos Mentis
General appearance : Calm
Blood pressure
: 110 / 70 mmHg
Heart Rate
: 96 x/min
Respiratory Rate
: 24 x/min
Temperature
: 37.6C
Weight
: 31 kg
Height
: 130 cm
d. ENT Examination
Auris dextra
Auricle
Tragus tendernes
Retroauricle

: Normal
:: Normal

R. SYAMSUDIN, SH HOSPITAL
EAR NOSE THROAT - HEAD AND NECK DEPARTMENT
Anthony (2010-061-136)
Mentor : dr. H. Oscar Djauhari , Sp. THT

Canalis Acoustic Externa

Tympanic Membrane

Auris sinistra
Auricle
Tragus tenderness
Retroauricle
Canalis Acoustic Externa

Nasi

Tympanic Membrane

: Hiperemic -, edema -, mass -, laceration -,

Secrete -, cerumen +
: Clearly visible, intact, light reflex +
: Normal
:: Normal
: Hiperemic -, edema -, mass -, laceration -,
Secrete -, cerumen +
: Clearly visible, intact, light reflex +

Inspection
: Normal, deformity (-)
Palpation
: Normal, crepitation (-)
Anterior Rhinoscopy
o Mucous membrane : Hiperemic +/+
o Septum
: Normal
o Concha
: Hipertrophy / hipertrophy
o Secrete
: +/+ (purulent)

Mouth and Neck

Pharynx
Palatine tonsil
Uvula
Posterior oropharynx
Teeth
Neck

: hyperemic : T2/T2, hyperemic : In the middle

: hyperemic
: Normal
: No enlargement of the lymph node

Maxilofacial
Inspection
Palpation

: Symetrical (smilling and frowning), deformity : Tenderness -, crepitation -

e. Resume
12 years old female patient came to R. Syamsuddin, SH Hospital with purulent
nasal discharge from both nose since 1 month ago. The discharge was foul odor,
purulent, and greenish. She also complaint blockade from both nose and difficulty
breathing. One week before came to the hospital, she felt pain in her face , between
her eye, difficulty in smelling anything, She didn't have any cough, fever, dental pain,
ear pain, sensation of fullness in the ear, or sore troat.

R. SYAMSUDIN, SH HOSPITAL
EAR NOSE THROAT - HEAD AND NECK DEPARTMENT
Anthony (2010-061-136)
Mentor : dr. H. Oscar Djauhari , Sp. THT

Anterior Rhinoscopy
o Mucousal membrane : Hiperemic +/+
o Concha
: Hipertrophy / hipertrophy
o Secrete
: +/+ (purulent)
Pharynx
: hyperemic Palatine tonsil
: T2/T2, hyperemic Palpation at sinus
: Tenderness -

f. Working Diagnosis
Suspect Acute Rhinosinusitis
g. Different Diagnosis
Sinus Neoplasm
h. Planning
- Outpatient
- H2O2 3%
-

Amoxicillin tab
Paracetamol tab
Control in 1 week

i. Prognosis
Quo ad vitam
Quo ad fungtionam
Quo ad sanationam

otic 3 dd gtt V AD
3 dd 500 mg mg per-oral for 14 days
500 mg per-oral if the patient is having fever or pain

: bonam
: dubia ad bonam
: dubia ad bonam