case sinusitis dr.oscar, sp.tht
TRANSCRIPT
CASE DISCUSSION
SINUSITIS
Supervisor
dr. H. Oscar Djauhari, Sp. THT-KL
PresentantsMarcella Aprilia Lonatrista 2010.061.150Arga Aditya 2008730006
Otolaryngology, Head and Neck DepartmentMedical Faculty of Unika Atma Jaya
Medical Faculty of Muhammadiyah Jakarta UniversitySyamsudin, S.H. Regional General Hospital, Sukabumi
26th November 2012 – 29th December 2012
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CASE DISCUSSION
A. PATIENT’S IDENTITY
Name : Ms. I
Gender : Female
Age : 28 years old
Occupation : employer
Address : Sukabumi
B. HISTORY
Chief Complaint : recurrent cold since 4 months before admission
Additional Complaints : headache, located at the base of the nose
History of Present Illness
A 28-year old woman came to ENT department at Syamsyudin hospital with a
chief complaint of recurrent cold at the morning since 4 month before admission. The
nose discharge had yellowish geen colour and smelled odour since 1 month before
admission. She also complained had nasal speech. Fever and cough were denied. She
had taken over the counter medication but she hadn’t feel any improvement. No
complainded on eyes.
History of Past Illness
History of right nose trauma three times since 11 years ago
History of hypertension was denied
History of Family Illness
History of family illness was denied
Habits
Recurrent cold
Does not smoke
Does not drink any alcohol substance.
Does not use any routine medication.
Does not use any narcotics.
C. PHYSICAL EXAMINATION
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General condition : Appear calm
Body weight : 45 kg
Height : 156 cm
Blood pressure : 110/90 mmHg
Pulse : 80 beat per minute
Respiratory rate : 22 times per minutes
Temperature : 36 oC
ENT Examination
Ear
Right ear
- Auricle : normal
- External auditory canal:
hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) , cerumen (-)
- Tymphanic membrane:
Intact, hyperemic (-), retraction (-), light reflex (+)
Left ear
- Auricle : normal
- External auditory canal:
hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) , cerumen (-)
- Tymphanic membrane:
Intact, bulging (-), light reflex (+)
Rinne test : air conduction is being louder or louder than bone conduction
on both ear
o Weber test : no lateralization
o Schwabach test : same with examiner on both ear
Nose
Right nose
- Mucous membrane:
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hyperemic (+), edema (+), secretion (+), mass (-), laceration (-), crust (-)
- Inferior conchae : eutrophy
- Septum : no deviation
- Air passage : decreased
Left nose
- Mucous membrane:
hyperemic (+), edema (-), secretion (+), mass (-), laceration (-), crust (-)
- Inferior conchae : eutrophy
- Septum : no deviation
- Air passage : normal
Oropharynx
- Posterior pharynx : hyperemic (-)
- Palatine tonsils : T1 / T1, hyperemic (-), detritus (-)
- Uvula : symmetrical
- Dental : no abnormatlities
Maxillofacial : symmetrical
Neck : no lymphadenopathy
D. WORKING DIAGNOSIS
Sinusitis
E. DIFFERENTIAL DIAGNOSIS
Allergic sinusitis
F. WORK-UP
Laboratory:
1. Routine blood count
2. Liver function test
3. Blood glucose test
4. Renal function test
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5. Bleeding time- clotting time
Roentgen thorax PA
Waters X-ray
ECG
G. TREATMENT
Antral Wash Out dextra
Ceftriaxone 2 x 1 gram vial
Ketorolac 3 x 1 ampul (@30 mg/ml)
Tranexamic acid 3 x 2 ampul (@ 250 mg/ml)
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Examination Normal value 11/9/2012 25/11/2012
Hemoglobin 12 -16 g/dl 12,9 11,9
Leucocyte count 4000 – 9000 / ul 10.100 7600
Hematrocryte 36,1
Thrombocyte 262.000
SGOT/ASAT < 31 U/L/37 C 22,0
SGPT/ALAT < 36 U/L/37 C 18,3
Ureum 20 -40 mg/dl 24,3
Creatinine < 0.9 mg/dl -1.1 mg/
dl
0,7
Bleeding time 1-3 minutes 2 minutes 1 minute
Clotting time 1-11 minutes 6 minutes 6. 30 minutes
Blood glucose < 180 mg/dl 86 108
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X-ray 1/11/2012: waters position
Right antrum wall thickened
Opaque cloaking seen at right maxillary sinus
Resume: sinusitis maxillary particularly dextra
chest x-Ray 11/9/2012: cor & pumo normal
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ECG 25/11/2012 : within the normal limit
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Follow up
26/11/2012
S: cold, pain at the forehead especially when she bows
O: Nose
Right nose
- Mucous membrane:
hyperemic (+), edema (+), secretion (+), mass (-), laceration (-), crust (-)
- Inferior conchae : eutrophy
- Septum : no deviation
- Air passage : decreased
Left nose
- Mucous membrane:
hyperemic (+), edema (+), secretion (+), mass (-), laceration (-), crust (-)
- Inferior conchae : eutrophy
- Septum : no deviation
- Air passage : normal
A: sinusitis
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26/11/2012
3.15 pm
S: Patient awake 2 hours after AWO. Patient feel sore on the right nose, headache, nausea,
blood taste inside the mouth, dry lips and thirsty
O: tampon on right nose
A: post-op sinusitis maxillaris dextra (AWO)
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