CASE REPORT

Day/Date:
Thursday, January 19th 2016
Doctors on duty:
Olvi, MD/Fahri, MD/Raya, MD-Dewi,
MD/Dila, MD- Ucha, MD
Consultant on Duty:
Harim Priyono, MD, ORL-HNS
Larynx Pharynx Consultant on Duty:
Bambang Hermani, MD, ORL, PhD
 Identity
Male, 35 years old

Chief complain
Swelling at left and right
neck area since 7 days
prior to admission
 MEDICAL HISTORY
Swelling at left and right neck area since 7 days prior to
admission. First swelling was appeared at right neck and
followed by the left neck since 5 days prior to admission
There was fever since 5 days prior admission
There was difficulty of opening the mouth since 4 days ago,
and difficulty of chewing and eating solid food since 4 days
ago. Patient only able to eat liquid food with straw.
There was history of muffled voice since 4 days ago
There was history of tootache at lower right 3 rd molar teeth
since 1 month ago but patient didnt visit the dentist
There was no history of fish bone stucked, lump at throat
area, short of breath and coughing
 MEDICAL HISTORY
History of diabetes mellitus was denied by the patient
and family. Patient never got blood check examination
before,
Patient was treated at Karawang General hospital for 4
days then referred to RSCM.
PHYSICAL EXAMINATION
ENT Examination
ENT Examination
 LABORATORY EXAMINATION CMER
(JANUARY 19TH, 2017)

Hb : 15.1 mg/dl January, 19th 2016 22.25

pH : 7,393
Ht : 46 %
pCO2 : 29.7
WBC : 21800 u/l
PO2 : 121.3
Platelet : 153000 u/l
SO2 : 98.4
PT : 9.9 (10,3)
BE : -4.8
APTT : 43,2 (36,6) HCO3 : 18.2
Ureum : 101 mg/dl Stand HCO3 : 20.5
Creatinine : 1.3 mg/dl Total CO2 : 19.2
AST : 40
ALT : 47
RBG : 203 mg/dl
Sodium : 138
Potasium : 4,4
Chlorida : 107
 RFL, CMER, January 19th 2017

Wide nasal cavity, no discharge,

eutrophy inferior turbinate,
adenoid was hypertrophy,
glotic rhyme was opened,
vocal and false vocal fold were
symmetric both in static and
dynamic, arytenoid not
hyperremic nor swelling, there
was standing secretion at left
pyriform sinus
WORKING DIAGNOSIS
 MANAGEMENT
Report to Bambang Hermani, MD, ORL,PhD
Incision and drainage with local anesthesia succeed,
evaluation : there was no pus, 2 pieces of gloves drain
were inserted.
Ampicillin Sulbactam 4x1.5 gram IV
Metronidazole 3x500 mg IV
Omeprazole 1x40 mg IV
Ketorolac 3x30 mg
Tredelenburg position
 CONSULTATION TO DENTISTRY
DEPARTMENT, JANUARY 20TH 2017
A : Ludovici Angina P:
- Plan for Panoramic
Radiography
-Scheduled for scalling
-Scheduled for multiple
excision under local
anesthesia (Surgical
tolerance from internal
medicine)
 CONSULTATION TO INTERNAL
MEDICINE DEPARTMENT, JANUARY
20TH 2017
A: P:
-Submandible abscess -Lab examination : Fasting
-Reactive Hyperglicemia glucose, 2 hour post
prandial glucose test,
dd/Type II DM
HbA1c, Lipid profile
-Currently there was no
indication for Diabetes
medication
-Diabetes diet 1900 kcal
 FOLLOW UP LARYNX PHARYNX
DIVISION
JANUARY 20TH 2017
S : Pain at incision area Vas 3, no short A : Deep neck abscess DD/Ludovici
of breath and fever angina
O : Conscious, no dyspneu stridor nor P : Vital sign observation
retraction IVFD Sodium Chloride
BP: 110/60mmHg RR: 18x/min
0.9% 500 ml/8 hours
T: 37 C HR: 88x/min O2 Sat: 99% (room
air) Ampicillin Sulbactam 4x1.5
Throat : 2 fingers trismus, poor oral gram IV
hygiene Metronidazole 3x500 mg IV
Colli region : There was conglomerated Omeprazole 1x40 mg IV
mass at right and left lymph region as
high level I,II , smooth in surface, warm
Ketorolac 3x30 mg
on palpation, fluctuative Tredelenburg position
Bethadine gargle 2x15 ml
 LABORATORY EXAMINATION CMER
(JANUARY 21ST, 2017)

Total Cholestrol : 116 mg/dl

HDL : 8 mg/dl
LDL : 76 mg/dl
Triglyceride : 103 mg/dl
HbA1c : 5.3 (N)
RBG : 130 g/dl
 FOLLOW UP LARYNX PHARYNX
DIVISION
JANUARY 21ST 2017
S : Pain at incision area VAS 3, no short of A : Deep neck abscess DD/Ludovici angina
breath and fever
P : Vital sign observation
O : Conscious, no dyspneu stridor nor IVFD Sodium Chloride 0.9%
retraction
500 ml/8 hours
BP: 110/60mmHg RR: 18x/min
T: 37 C HR: 88x/min O2 Sat: 99% (room air)
Ampicillin Sulbactam 4x1.5
gram IV
Throat : 3 fingers trismus, poor oral hygiene
Metronidazole 3x500 mg IV
Colli region : There was conglomerated Omeprazole 1x40 mg IV
mass at right and left lymph region as high
level I,II , smooth in surface, warm on Ketorolac 3x30 mg
palpation, fluctuative Tredelenburg position
Bethadine gargle 2x15 ml
Scheduled for Neck CT-Scan
(Contrast)