Case Report

Day/Date : Monday/January 24th 2022

Doctors on duty : Rizki/Nel/Rini-Mizwar-If/Hazazi-Fio
Consultant : Al Hafiz, MD, ORL-HNS (C),FICS

Department of Otorhinolaryngology Head and Neck Surgery

Faculty of Medicine Andalas University/Dr. M. Djamil Hospital
Padang
 Identity of Patient
Male, 52 years old

Chief Complaint
(Alloanamnesis)
Felt fatigue getting worse since a day before admission
 Medical History
Patient had been known with squamous cell
carcinoma nasopharynx non keratinizing stage III
(T3N1M0), patient had gone trough
chemoradiotheraphy since Desember 2020. The
patient then was scheduled for adjuvant
chemotherapy, but the patient stop at 2nd adjuvant
chemotherapy. The last time patient visited
outpatient ORL-HNS clinic was at August 2021.
 Medical History
Patient felt fatigue since 1 month before admission,
then fatigue got worse since a day before admission,
patient is brought by family to emergency
department of Dr. M. Djamil Hospital Padang
Patient lost appetite since a month ago
There was history of headache intermittenly since 1
month ago
 Medical History
There was lump at the right neck since 1 year ago
There was no enlargement lump at another part of
body
There was no nasal congestion
There was no fullness sensation of the ear
There was no double visions
There was no history blood came out from the nose
There was no decrease of hearing
 Medical History
There was no buzzing ear
There was no seizure
There was no projectile vomite
There were no pain and difficulty opening the mouth
There was no pain in swallowing
There was no drooling
There was no saliva mixed with blood
There was no decrease of conciousnes
 Medical History
There were no pain and difficulty moving the neck
There was no difficulty of breathing
There was no history of consuming alcohol
There was no history of malignancy in the family
There was history of smoking, 1 packs per day for 20
years, and had stop since 3 years ago
There was no history of cooking with firewood
There was no history of eating salted fish
 Medical History
There was decreased of body weight > 10 kgs in 3
months
There was no history of hypertension
There was no history of diabetic mellitus
 General Examination
General condition was moderately ill, composmentis,
GCS E4V5M6

BP : 110/ 70 mmHg
PR : 97 x/min
RR : 17 x/min
T : 36.5⁰ C
Eyes
Anemic conjunctiva +/+, icteric sclera -/-
 ENT Examination
Ear
Right :
Ear canal was wide, tympanic membrane was intact,
cone of light (-)

Left :
Ear canal was wide, tympanic membrane was intact,
cone of light (-)
 ENT Examination
Nose
Right Nasal Cavity
Nasal cavity was wide, inferior and middle turbinate
were eutrophy, septal deviation (-), discharge (-),
mass (-)

Left Nasal Cavity

Nasal cavity was wide, inferior and middle turbinate
were eutrophy, septal deviation (-), discharge (-),
mass (-)
 ENT Examination
Throat
Pharyngeal arch was symmetric, uvula in the midline,
tonsil T1-T1 not hyperemic, pharyngeal wall was not
hyperemic

Posterior Rhinoscopy
Could not be evaluated
 ENT Examination
Colli Region
Right
Lymph node enlargement
(+) level II, size 15x10x5mm,
immobile (+), tenderness (-),
hyperemic (-)

Left
There was no enlargement
lymph node
Pictures of patient
 Cranial Nerve Examination
• CN. I : decreased of smelling (-)
• CN. II : pupillary light reflex (+)
• CN. III, IV, and VI : ptosis (-), The movement of eyes was free
• CN. V : numbness at the cheek (-)
• CN. VII : skewed face (-)
• CN. VIII: vertigo (-)
• CN. IX : pharyngeal arch was symmetric
• CN. X : gag reflex (+), hoarseness (-)
• CN. XI : no difficulty in moving the shoulder
• CN. XII : no deviation
 Laboratory Finding
Hb : 7,5 g/dl Ur : 50 mg/ dl
Leu : 8780 /mm3 Cr : 1,8 mg/ dl
Ht : 23 % Na : 126 mmol/L
Trombo : 437.000/mm3 K : 4.0 mmol/L
Diff count : 0/5/82/9/4 Cl : 101 mmol/L
PT : 10,9 sec SGOT : 16 u/l
APTT : 41,8 sec SGPT : 11 u/l
RGB : 111 mg/dl

Result : anemia, eosinophilia, neutrofilia, trombositosis,

APTT , creatinin
 Working Diagnosis

Working • Squamous cell carcinoma nasopharynx non

Diagnosis keratinizing stage III (T3N1M0) Post
chemoradiotheraphy
• Anemia
• Acute kidney injury
• Hyponatremia
ICD 10 • Malignant neoplasm of nasopharynx (C11.9)
• Anemia, unspecified (D64.9)
• Acute kidney failure, unspecified (N17. 9)
• hyponatremia (E87.1)
 Management
Consulted to Internal Medicine Department
Inwarded at ORL-HNS Department
Consulted to Clinical Nutrition Department
Consulted to Oncology ORL-HNS Subdivision
Therapy:
- IVFD NaCl 0,9% 8 hours/kolf
- Paracetamol 3x500mg (orally)
 Internal Medicine Department
A/
- Moderate anemia caused by chronic disease
- Hypocoagulation
- Acute kidney injury stage I caused by pre-renal
caused by dehydration
- Hyponatremia
 Internal Medicine Department
P/
- Perform complete peripheral blood if there is no
hemolytic sign
- Transfusion PRC until Hb >10 gr/dL
- Therapy : IVFD NaCL 0,9% 1 kolf/6 hours
- Positif fluid balance
- Perform ureum and creatinine test every 3 days,
urinalysis
- Monitor for any sign of bleeding
THANK YOU
References
References
References
 Oncology subdivision follow up
• S : Fatigue (+)
Fever (+)
• O : General condition : moderately-ill,
Composmentis cooperative
• A : Squamous cell carcinoma nasopharynx non
keratinized stage III (T3N1M0)
 Oncology subdivision follow up
• P: Vital sign monitoring
Planned for PRC transfusion
NacL 0,9 % 20 drops/minute
MST tablet 10 mg 1x1 (orally)