Case report

PATIENT IDENTITY• Name : KJ• Medical Record : 40.01.08• Age : 8 years old• Sex : male• Job : student• Address : JR. Pintu Padang Madat,

Tunggul-Pasaman Timur

Anamnesis

ANAMNESIS• A male, 8 years old, came to ENT – HNS Department of Dr.

M. Djamil Hospital on February, 16th , 2015 with:Chief Complaint :• Pain when swallow since 1 week agoClinical Course :• Pain when swallow since 1 week ago. Pain was felt when

swallow saliva or when eating food.• Initially, Pain swallowing felt since 9 months ago,

intermitten. It was felt especially when patient has a fever, cough and cold

Anamnesis

• The patient's family said, since 9 months ago, patients snore while sleeping and some times awakened from sleep due to shortness of breath.

• The patient's family said that the patient's mouth, smell bad since 9 months ago.

• There are fever since 9 months ago, approximately 8 times in 9 months accompanied by cough and colds.

• There was pain in the left ear accompanied by ringing in the ears, especially when the patient has a fever. Hearing loss does not exist.

• Hoarseness since 3 months ago.• Patients like drinking ice and eat snacks at school almost every

day.

• There are no sneezing in the morning nor history of drug allergy and food.

• There are no breathless• The patient had been treated in public health centers

and diagnosed with enlargement of tonsils and received the drug from the family doctor but forgot the name of the medicine.

AnamnesisPast Medical History• The patient has been suffering from complaints like this since 9

months ago• The patient had no history of asthma, nor allergies to food or

drugs and never sneezing in the morning more than 5 times.• The patient had been treated previously for diseases like this. History of Familial Disease• There is no family members that have same symptoms or

disease same with patient.• There is no atophy in family. History of Work, Social, Economy and Habit• Patient is an elementary school student• Patients often consume ice and snacks at school almost every

day.

Physical examinationGeneralis State• General appearance : good• Awareness : CMC• Blood Pressure : 110/ 70• Heart Rate : 90x/minutes• Respiratory Rate: 20 x/minutes• Temperature` : 37 oC• Head : Normocephal • Eyes : Conjunctiva : anemic (-) , Sclera : icteric (-)• Pulmo : Within normal limits• Cor : Within normal limits• Abdomen : Within normal limits• Extremitas : Within normal limits

EAR, NOSE, AND THROAT EXAMINATION

Examination Abnormality Dekstra Sinistra

AuricularCongenital abnormality - -

Trauma - -Inflammation - -Metabolic disorder - -

Retraction pain - -Tragus pain - -

Wall and canal of earWide enough (N) Wide enough (N) Wide enough(N)Narrow - -Hyperemic - -Oedema - -Mass - -

Secrete/cerumenStink - -Colour yellowish yellowishAmount A few A fewType dry dry

Tymphany membrane

IntactColor White whiteReflect of light + +Bulging - -Retraction - -Atrophy - -

PerforationAmount of perforation - -

Type - -Quadran - -Margin - -

Picture

MastoidInflammation sign - -Fistula - -Cicatrix - -Tenderness - -

Tuning fork testRinne + +Schwabach normal NormalWeber there’s no lateralisation Conclusion Normal

Audiometry Not examined

NOSE, PARANASAL SINUS

Examination Abnormality Dextra Sinistra

Outer noseDeformity - -Congenital abnormalities

- -

Trauma - -Inflammation - -Mass - -

Examination Dextra Sinistra

Tenderness - -

Paranasal Synus

Examination Abnormality Dextra Sinistra Vestibulum Vibrise + +

Inflammation - -

Cavum nasal Wide enough (N) + +

SecreteLocation + +Type serous serousAmount A few A fewSmell - -

Inferior Concha Size eutrophy EutrophyColour Pink PinkSurface smooth SmoothOedema - -

Middle Concha Size eutrophy eutrophyColour pink pinkSurface smooth smoothOedema - -

SeptalDeviation - -Surface Smooth SmoothColour Pink Pink Spina - -Crista - -Abscess - -Perforation - -

MassLocation - -Form - -Size - -Surface - -Colour - -Consistency - -Easily swayed - -Vasoconstrictor - -

RHINOSCOPY POSTERIORExamination Abnormality Dextra Sinistra

ChoanaWide enough (N)

NarrowWide difficult to assess difficult to assess

MucosaColour

difficult to assess difficult to assess

Oedema difficult to assess difficult to assessGranulation tissue difficult to assess difficult to assess

Inferior conchaSize

difficult to assess difficult to assess

Colour difficult to assess difficult to assessSurface difficult to assess difficult to assessOedema difficult to assess difficult to assess

Adenoiddifficult to assess difficult to assess

Eustachian tube orificium Secretedifficult to assess difficult to assess

Mucosa oedema difficult to assess difficult to assess

MassLocation

difficult to assess difficult to assess

Size difficult to assess difficult to assess

Form difficult to assess difficult to assessSurface difficult to assess difficult to assess

Post Nasal Dripdifficult to assess difficult to assess

Type difficult to assess difficult to assess

OROPHARYNX AND MOUTHExamination Abnormality Dextra Sinistra

Pharyngeal archPalatum mole

Simetris SimetrisColour PinkOedema -Spot/exudates -

Pharyngeal wall Colour PinkSurface Not Flat

TonsilSize T3 T4Colour hiperemic hipremicSurface Not Smooth Not SmoothCrypt enlargement enlargementDetritus - +Exudate - -Adhesion with pillar - +

PeritonsilColour hiperemic hiperemicOedema - -Abscess - -

TumorLocation - -Form - -Size - -Surface - -Consistency - -

Teeth Caries/Radix - +Conclusion Lack of oral hygiene

TongueColour PinkForm NormalDeviation -Mass -

Picture

LARYNGOSCOPY INDIRECTExamination Abnormality Dextra Sinistra

EpiglotisForm difficult to assessColour difficult to assessOedema difficult to assessMargin difficult to assessMass difficult to assess

AriteniodColour difficult to assess difficult to assessOedema difficult to assess difficult to assessMass difficult to assess difficult to assessMovement difficult to assess difficult to assess

Ventrikular bandColour difficult to assess difficult to assessOedema difficult to assess difficult to assessMass difficult to assess difficult to assess

Plica vocalisColour difficult to assess difficult to assessMovement difficult to assess difficult to assessMedial margin difficult to assess difficult to assessMass difficult to assess difficult to assess

Subglotis/trachea Mass difficult to assess difficult to assessSecrete difficult to assess difficult to assess

Sinus piriformis Mass difficult to assess difficult to assessSecrete difficult to assess difficult to assess

Vallecula Mass difficult to assess difficult to assessSecrete (type) difficult to assess difficult to assess

Picture

Cervical Examination

• there are enlargement of lymph nodes below the left mandible,as much as 1 piece of round shape, size 1x1x1 cm, chewy consistency, mobile

Diagnosis

• Working diagnosis : Chronic Tonsillitis• Secondary diagnosis : Caries of Dentis

Prompts Examination:

- Routine laboratory: hemoglobin, hematocrit, leukocytes, LED

- Culture and resistance tests of bacterium of the tonsils.

Therapy

• Ceftriaxone 1x500 mg IV• Metylprednisolone 3x4mg

• Planning : Tonsilectomy

Laboratory examination (February, 17th.2015)

• Hb : 12,8 g/dl• Leucocytes: 20370/mm3

• Ht : 34%• Trombosite : 513000/mm3

• Pt : 9,4 second• Aptt : 29,6 second

Discussion

•a boy patient, 8th years old which diagnose chronic tonsillitis•based on anamnesis and physical examination.

Has been reported

•Pain when swallow since 1 week agochief complaint

•Pain when swallow since 1 week ago. Pain was felt when swallow saliva or when eating food.•Initially, Pain swallowing felt since 9 months ago, intermitten. It was felt especially when patient has a fever, cough and cold

•The patient's family said, since 9 months ago, patients snore while sleeping and some times awakened from sleep due to shortness of breath.

•The patient's family said that the patient's mouth, smell bad since 9 months ago.•There are fever since 9 months ago, approximately 8 times in 9 months accompanied by cough and colds.•There was pain in the left ear accompanied by ringing in the ears, especially when the patient has a fever. Hearing loss does not exist.

•Hoarseness since 3 months ago.•Patients like drinking ice and eat snacks at school almost every day.

Clinical course

•Within of normal limitsGeneral examination

•Enlargement of tonsill, size T3-T4•Detritus +, adhesion of pilar +

Ear, nose, throat examination

•there are enlargement of lymph nodes below the left mandible,as much as 1 piece of round shape, size 1x1x1 cm, chewy consistency, mobile

Cervical examination

Chronic Tonsillitis

Additional Examination

•Routine laboratory: hemoglobin, hematocrit, leukocytes, LED•Culture and resistance tests of bacterium of the tonsils.

In this patient •laboratory examination : leucocytosis

•Ceftriaxone 1x500 mg IV•Metylprednisolone 3x4mg•Mouthwash containing disinfectant•Planning : Tonsilectomy

treatment