FINAL EXAM CASE PRESENTATION

EAR NOSE THROAT - HEAD AND NECK DEPARTMENT

R. SYAMSUDIN, SH HOSPITAL, SUKABUMI

Examined by :
dr. Oscar Djauhari, Sp. THT

Presented by :
Cindy Maharani Putri 201706010193

Clinical Rotation
Ear, Nose, Throat, Head and Neck Departement
Medical Faculty of Unika Atma Jaya Jakarta
Syamsudin, S.H. Regional General Hospital, Sukabumi
October 22– November 17 2018
 R. SYAMSUDIN, SH HOSPITAL
EAR NOSE THROAT - HEAD AND NECK DEPARTMENT
CHINTYA (2015061134)
DR. OSCAR DJAUHARI, SP.THT

Final Exam Case Presentation

A. Identity
Name : Boy. F
Age : 13 years old
Sex : Male
Occupation : Junior high school students
Address : Sukabumi
Religion : Moslem
Race : Sundanese

B. Anamnesis
Chief complaint :Lump on the left neck, which are getting bigger since
± 2 month of admission
Additional complaint :Nasal congestion, nasal discharge, epistaxis, hearing
loss (left ear)
History of Present Illness :
Patient came to ENT clinic R. Syamsudin, SH hospital with a complaint of
lump in the left neck since two months ago and increasing in size since then.
Patient said that the lump first appear as big as marble, and then increasing size into 3
cm x 3.5 cm, the lump consistency is hard, cannot be moved, and painless.
He also complained about Left nasal congestion since six months ago, with
nosebleeding that appear ± once in 2 days. And then since ± 1 week before
admission patient complaining about excessive nasal discharge from the left nose,
the discharge is greenish, purulent, and have foul odor. The discharge from the
nose is felt out every day without being affected by changes in temperature, exposure
to dust or exposure to furry animals. In addition, the patient complained of hearing
loss in the ear nose since ± 6 months before admission and the patient said the ear
felt full. Other complaints such as fever are denied.
 R. SYAMSUDIN, SH HOSPITAL
EAR NOSE THROAT - HEAD AND NECK DEPARTMENT
CHINTYA (2015061134)
DR. OSCAR DJAUHARI, SP.THT

History of previous illness :

- History of same symptoms was denied
- History of diabetes mellitus was denied
- History of hypertension was denied
- History of cardiovascular disease was denied
- History of cerebrovascular disease was denied

History of allergy :
- History of allergy was denied
- History of allergy in family was denied

History of family illness:

- History of family illness was denied
- History of neoplasm in family was denied

History of habit :
- Patients consume salted fish more than once a week

C. Physical Examination
Consciousness : Compos Mentis
General appearance : Moderately ill
Blood pressure : 110/70 mmHg
Heart Rate : 88 x/min
Respiratory Rate : 20 x/min
Temperature : 37.5°C
Weight : 47 kg
Height : 145 cm

D. ENT Examination
Auris dextra
 Auricle : Normal
 Tragus tendernes :-
 R. SYAMSUDIN, SH HOSPITAL
EAR NOSE THROAT - HEAD AND NECK DEPARTMENT
CHINTYA (2015061134)
DR. OSCAR DJAUHARI, SP.THT

 Retroauricle : Normal
 Canalis Acoustic Externa : Hiperemic -, edema -, mass -, laceration -,
Secrete -, cerumen -
 Tympanic Membrane : Clearly visible, intact, light reflex +

Auris sinistra
 Auricle : Normal
 Tragus tenderness :-
 Retroauricle : Normal
 Canalis Acoustic Externa : Hiperemic -, edema -, mass -, laceration -,
Secrete -, cerumen -
 Tympanic Membrane : Clearly visible, intact, light reflex +

Nasi
 Inspection : Normal, deformity (-)
 Palpation : Normal, crepitation (-)
 Anterior Rhinoscopy
o Mucousal membrane : Hyperemic -/-, Edem -/-
o Septum : Normal
o Concha : Hipertrophy -
o Secrete : -/+

Oropharynx
 Pharynx : hyperemic -
 Palatine tonsil : T1/T1, hyperemic -
 Uvula : In the middle
 Posterior oropharynx : hyperemic -
 Teeth : caries –
 R. SYAMSUDIN, SH HOSPITAL
EAR NOSE THROAT - HEAD AND NECK DEPARTMENT
CHINTYA (2015061134)
DR. OSCAR DJAUHARI, SP.THT

Maxilofacial
 Inspection : Symetrical (smilling and frowning), deformity -
 Palpation : paranasal sinus tenderness -/-

Neck
 Lymph Node : found one enlarging lymph nodes (Left cervical
lymph node, size 3x3.5 cm, immobile, painless, consistency is hard)

E. Resume
13 years old male patient came to R. Syamsudin, SH Hospital with complaint
of Lumps in the left neck, size 3 x 3.5 cm, immobile, painless, consistency is hard
± 2 months ago, Left nasal congestion since ± 6 months ago with nosebleeding that
appear ± once in 2 days, nasal discharge from the left nose since ± 1 week before
admittion, the discharge is greenish, purulent, and have foul odor. In addition, the
patient complained of hearing loss of the left ear since ± 6 months of SMRS and the
patient said the ear felt full.

F. Working Diagnosis
- Suspect nasopharyngeal carcinoma, with enlargement of the left cervival lymph
nodes

G. Differential Diagnosis
- Laryngitis tuberculosis

H. Planning
- Laboratory
- Complete blood count (hemoglobin, hematocrit, leukocyte and differential
count, thrombocyte)
- IgA
- Fungsi hati
 R. SYAMSUDIN, SH HOSPITAL
EAR NOSE THROAT - HEAD AND NECK DEPARTMENT
CHINTYA (2015061134)
DR. OSCAR DJAUHARI, SP.THT

- X-ray thorax
- CT-Scan in coronal and axial position
- MRI
- FNAB
- Nasopharyngoscopy + biopsy

I. Therapy
1. If the biopsy shows malignancy in nasopharynx, do the radiotherapy and
chemoterapy based on the staging.

J. Prognosis
 Quo ad vitam : malam
 Quo ad fungtionam : malam
 Quo ad sanationam : malam