Case Report

Day/ Date : Monday/ January 2nd 2017

Doctors on duty : Dewi/ Danon/ Apri/ Loren-Iin
Consultant : Rossy Rosalinda, MD, ORL

Department of Otorhinolaryngology Head and Neck Surgery

Faculty of Medicine Andalas University/ Dr. M. Djamil Hospital
Padang
 Identity of Patient
Girl, 1 year 6 month old

Chief Complaint (Alloanamnesis)

Bleeding came out from the left nostril 2 hours
before admission
 Medical History
Bleeding came out from the left nostril 2 hours
before admission
Previously the patient was fallen while walking, her
face bump the floor, after that there was bleeding
came out from the left nostril about 3 drops, stopped
spontaneously, she brought to Private Hospital and
referred to Dr. M. Djamil Hospital
The patient still conscious after the incident
There was swelling at the upper lip
There was no swelling on the nose
 Medical History
There was no difficulty in breathing
There was no swelling at the cheek
There was no pain and difficulty in opening the
mouth
There was no bleeding from the ear and the mouth
There was no wound at other part of the body
There was no history of scratching the nose
There was no fever, cold and cough
 General Examination
General condition was moderately ill, composmentis

RR : 22 x/min
PR : 92 x/min
T : 36.7 oC
BW : 10 kg
 ENT Examination
Ear
Right ear:
Ear canal was wide, tympanic membrane was intact,
cone of light (+)

Left ear:
Ear canal was wide, tympanic membrane was intact,
cone of light (+)
 ENT Examination
Nose
Edema (-), deformity (-), alignment is straight,
excoriation (-), laceration (-), tenderness (-), crepitation (-)

Right nasal cavity:

Nasal cavity was wide, inferior and middle turbinate were
eutrophy, clotting (-), active bleeding (-), septal
deviation (-), septal hematoma (-), septal dislocation (-),
septal fracture (-)
 ENT Examination
Left nasal cavity:
Nasal cavity was narrow, inferior turbinate was edema,
middle turbinate difficult to evaluated, septal
deviation (-), hyperemic (+) at kiesselbach plexus, septal
hematoma (-), dislocation (-), septal fracture (-), clotting
(+), active bleeding (-)
 ENT Examination
Oral cavity
Trismus (-), malocclusion (-), chemosis at palate (-)
Throat
Pharyngeal arch was symmetric, uvula in the midline,
tonsil T1-T1 hyperemic (-), posterior pharyngeal wall
clotting (-), active bleeding (-)
 ENT Examination
Frontal region
Laceration (-), excoriation (-), edema (-),
crepitation (-), tenderness (-)
Zygoma region
Laceration (-)/(-), excoriation (-)/(-), edema (-)/(-),
crepitation (-)/(-), tenderness (-)/(-)
Maxillary region
Laceration (-)/(-), excoriation (-)/(-), edema (-)/(-),
crepitation (-)/(-), tenderness (-)/(-)
 ENT Examination
Nasolabial region
Edema (+) at left side, laceration (-), excoriation (+),
crepitation (-), tenderness (+)
Mandibular region
Edema (-)/(-), laceration (-)/(-), excoriation (-)/(-),
crepitation (-)/(-), tenderness (-)/(-)
TMJ region
Edema (-)/(-), laceration (-)/(-), excoriation (-)/(-),
crepitation (-)/(-), tenderness (-)/(-), dislocation (-)/(-)
Picture of patient
 Working Diagnosis

Diagnosis • Post epistaxis caused by nasal

blunt trauma
• Nasolabial blunt trauma
ICD 10 • Epistaxis (R04.0)
• Unspecified injury of nose
(S09.92XA)
 Management
Nasal toilet
Applied chloramphenicole ointment
Therapy:
– Ibuprofen 100 mg 3 x 1 teaspoon
Control to ORL-HNS outpatient clinic 3 days later