BEDSIDE TEACHING Tonsillitis

Disusun Oleh : Nur Hamizah Nasaruddin 130110082001

Preceptor : Prof. Dr. Teti HS Madiadipoera dr., Sp THT-KL (KAI)., FAAAAI

BAGIAN ILMU KESEHATAN TELINGA HIDUNG TENGGOROK BEDAH KEPALA DAN LEHER FAKULTAS KEDOKTERAN UNIVERSITAS PADJADJARAN RS DR. HASAN SADIKIN BANDUNG 2012

PATIENTS IDENTITY Name Gender Age Address Education Religion Status : Tn Rangga M Setiawan : Male : 14 years : Jalan Derwai : Student : Islam : Single

Date of Examination : 18th April 2012 ANAMNESIS Chief Complaint Specific Complaint : Sensation of foreign object in throat :

One week before the patient came to RSHS, he started having the sensation of a foreign object stuck in his throat. The complaint begins abruptly and then progressed in the inclination of sore throat. Difficulty and pain during swallowing were reported with the ability to only swallow food in liquid form. The patient denied having any voice changes or the presence of stridor. The patient also complained of snoring and difficulty in breathing that woke him up during sleep many times. History of fever was confirmed positive by the patient, along with ear pain and tinnitus. History of ear discharge was denied by the patient. History of coughing and having flu were denied by the patient. There was no history of foreign body ingestion or any other illness before the onset of symptoms. He has not taken any types of medications to alleviate his symptoms. The patient has a history of allergy, specifically to dust and seafood. History of nasal obstruction, nasal itching, nasal discharge together with posterior nasal drip were all reported by the patient, but he denied having headaches. The nasal discharge was clear white, with no foul odour. Symptoms occured mainly in the morning and during exposure to dust. He

confirmed of having a visit to the Specialist Polyclinic in RSHS around 6 months ago to cure his allergy. History of medication prescribed to him were nasal spray(Avomys) and cetirizine tablets.The patient also reported having a family history of asthma. PHYSICAL EXAMINATION Consciousness General condition Cyanosis Dyspnea Dehydration Edema Vital Signs : Compos mentis : Moderately ill ::::: Blood pressure Pulse Respiratory Rate Temperature GENERAL STATUS Head Neck Chest : conjunctiva not anemic Sclera not icteric : JVP within normal limit : Shape and movements symmetric Pulmo Cor Abdomen Extremities : sonor, VBS right = left : heart sound within normal limit Lymph Node : within normal limits = 120/80 mmHg = 84 x/min = 20 x/min = 37,8 0C

: flat, supple, bowel sound + normal Liver and spleen not palpable : within normal limit

LOCAL STATUS Ear Parts Preauricle Auricle Abnormalities Congenital Inflammation and tumor Trauma Congenital Inflammation and tumor Trauma Edema Hyperemia Pain on touch Cicatrix Fistule Fluctuation Congenital Skin Secretions Cerumen Edema Mass Cholesteatoma Colour Intact Light Reflex Tympanic Membrane Auricle Dextra Normal + Greyish white (+) (+) Sinistra Normal Greyish white (+) (+)

Retroauricle

External Acoustic Canal

Hearing Test Rinne Test Weber Test Schwabach Test :

Auricle Dextra Sinistra (+) (+) No lateralization No lateralization N N

Nose Examination External Shape and Size Mucous Secretions Crusts Inferior Concha Septum Polyp/tumor Airway Passage Nasal Dextra Sinistra Within normal limits Within normal limits Normal Normal (-) (-) Eutrophy Eutrophy No Deviations Not found Not found + +

Anterior Rhinoscopy

Nasopharynx Examinations Mucous Choana Secretions Torus tubarius Fossa Rosenmuller Nasal Dextra Normal Open + Normal Normal Sinistra Normal Open + Normal Normal

Posterior Rhinoscopy

Oral Cavity Parts Abnormalities Oral mucous Tongue Soft Palate Teeth Uvula Halitosis Descriptions Normal Clean, wet, N movements in all directions Normal Caries (+) 3 7, 4 7 In the middle (-)

Mouth

Oropharynx Parts Abnormalities Mucous Size Crypts Detritus Attachments Descriptions Hyperemia T2 T3 Enlarged (+/+) (-/-)

Tonsil

Pharynx

Mucous Granules Post nasal drip

Hyperemia (+) (-)

Larynx Parts Abnormalities Epiglottis Arytenoid Cartilage Ariepiglottal Plica Vestibular Plica Vocal Plica Tracheal ring Rima glotis Descriptions Normal (+), mass (-) Normal +/+, mass -/Normal +/+, mass -/Normal +/+, mass -/Normal +/+, simmetry Normal +/+, mass -/Open

Larynx

Maxillofacial Shape : Symmetry Cranial Nerve Paresis : Not found

Neck Lymph Node Mass : Not enlarged : Not found

LOCAL STATUS(simplified): ADS : External Auricular Canal within normal limits +/ +, secretions -/ -, cerumen -/ Tympanic Membrane intact/intact, Light Reflex +/ +, Retroauricular within normal limits +/ +. CN : Mucous membrane within normal limits +/+, secretions -/-, inferior concha eutrophy +/ +, Septum Deviation -, Airway Passage +/ +. NPOP : To = T2 T3 hiperemis, enlarged crypts, detritus (+), hyperemic pharynx with granules (+) MF : Symmetrical, Cranial Nerve Paresis (-) : +/+ : No lateralization Neck : Lymph Nodes palpated were not enlarged Rinnes Test Weber Test

Schwabach Test : normal / normal PROBLEMS: Sensation of foreign object in throat Sore throat Pain during swallowing Difficulty in swallowing Ear pain Tinitus Snoring Difficulty breathing History of fever History of allergy (+) History of allergic rhinitis (+) Tonsils enlarged T2-T3, hyperemia, enlarged crypts, detritus (+) Hyperemic pharynx, granules (+)

HYPOTHESIS: Acute Exacerbation of Chronic Hypertrophic Tosillitis + Acute Pharyngitis + Fibroma Tonsil Tonsillitis Diphteria

Chronic Rhinitis ec Suspect Dust Allergy

WORKING DIAGNOSIS: Acute Exacerbation of Chronic Hypertrophic Tosillitis + Acute Pharyngitis +

Chronic Rhinitis ec Suspect Dust Allergy

FURTHER EXAMINATIONS Routine Lab Examinations (Hb, L, Tr, Ht), differential count Tonsillar swab culture and resistency test Nasoendoscopy Skin Prick Test

TREATMENT General: Avoid exposure to allergens (dust), maintain physical fitness and avoid consumptions of spicy food Medicamentosa: PROGNOSIS Quo ad vitam Quo ad functionam : ad bonam : ad bonam Amoxicillin 3 x 500 mg Paracetamol 3 x 500 mg Cetirizine 1 x 1 Avomys 1 x 2