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LAPORAN KASUS

FARINGITIS

Pembimbing
dr. Indra Setiawan, Sp.THT-KL

Zanty Rakhmania Putri


201710401011053

SMF Telinga Hidung dan Tenggorok


Rumah Sakit Bhayangkara Kediri
Fakultas Kedokteran Universitas Muhammadiyah Malang
2018
Identitas
 Nama : Nn. N
 Jenis kelamin : Perempuan
 Usia : 22 tahun
 Alamat : Ngadirejo, Kediri
 Agama : Islam
 Pekerjaan : pegawai
perusahaan swasta
 Tgl Pemeriksaan : 12 Desember 2018
Anamnesis
 Keluhan Utama : Nyeri tenggorok
 Riwayat Penyakit Sekarang :
 Pasien datang ke Poliklinik THT RS Bhayangkara
Kediri dengan keluhan nyeri tenggorok, yang terutama
dirasakan saat menelan (nyeri telan) 2 hari ini. Ada rasa
mengganjal dan tertusuk di tenggorokan. Seminggu ini,
merasa lelah karena mobilitas tinggi, makan tidak teratur.
Nafsu makan menurun. Badan terasa lemas. Batuk (+)
berdahak, namun dahak tidak dapat keluar 2 hari ini,
darah (-). Demam (+) sumer-sumer, menggigil (-). Nyeri
kepala(+) 2 hari ini. Suara serak (-). Mengorok (-). Mual (-)
muntah (-). Pilek (-) hidung tersumbat (-). Keluhan telinga
seperti nyeri telinga (-) keluar cairan (-).
• Sakit seperti ini (+) terakhir 3 bulan lalu
• Sebelumnya sering batuk pilek
RPD • Asma (-)

• Sakit seperti ini (-)


• R. Alergi (-)
RPK

• Seminggu ini pasien merasa lelah karena mobilitas tinggi


• Makan tidak teratur
Rsos • Makan makanan berminyak disangkal
• Belum pernah diobati
R. Obat

• Obat (-)
R. Alergi • Makanan (-)

• Tonsilektomi tahun 2007


R. Operasi
Pemeriksaan Fisik
Status Generalis
Keadaan Umum: Baik

Kesadaran: CM (GCS 456)

Vital sign:
• Tensi: 110/70 mmHg
• Nadi: 88x/menit
• RR:20x/menit
• Suhu: 37.8 C
Status Generalis
Kepala

• A/I/C/D : -/-/-/-

Leher

• Tidak teraba pembesaran KGB

Abdomen

• DbN

Ekstrimitas

• Akral Hangat, CRT <2 detik


Status Lokalis

Telinga
BAGIAN DEXTRA SINISTRA
Auricula Bentuk normal, benjolan (-), Bentuk normal, benjolan (-),
nyeri tekan (-) nyeri tekan (-)
Periauricula Nyeri tekan tragus(-), fistula (- Nyeri tekan tragus(-), fistula (-
), abses (-) ), abses (-)
Retroauricula Nyeri tekan (-), edema (-), Nyeri tekan (-), edema (-),
hiperemis (-) hiperemis (-)
Mastoid Nyeri tekan (-), edema (-), Nyeri tekan (-), edema (-),
hiperemis (-) hiperemis (-)
MAE Sekret (-), serumen (-), Sekret (-), serumen (-),
hiperemis (-), edema (-), hiperemis (-), edema (-), corpal
corpal (-) (-)
Membran timpani
• Perforasi (-) (-)
• Cone of light (+) arah jam 5 (+) arah jam 7
• Warna Hiperemis (-) Hiperemis (-)
• Bentuk Normal Normal
• Retraksi (-) (-)
• Sekret (-) (-)
• Bombans (-) (-)
Status Lokalis

Hidung
Hidung Dextra Sinistra
Rinoskopi anterior
- Vestibulum Nasi Lebar lubang Lebar lubang
hidung hidung
normal, krusta normal,
(-), bisul (-) krusta (-),
bisul (-)
- Kavum Nasi Hiperemis (-), Hiperemis (-),
sekret (-), sekret (-),
rambut (+) rambut (+)
- Selaput Lendir Hiperemis (-), Hiperemis (-),
edema (-) edema (-)

- Septum Nasi Deviasi (-), Deviasi (-),


massa (-) massa (-) - Meatus nasi inferior Sekret (-) Sekret (-)
- Konka media Sulit dinilai Sulit dinilai
- Lantai + dasar Licin, massa (- Licin, massa - Meatus nasi media Sekret (-), Sekret (-),
hidung ) (-)
polip (-) polip (-)
- Konka inferior Hiperemis (-), Hiperemis (-),
edema (-), edema (-), - Polip - -
permukaan permukaan - Korpus alienum - -
licin licin - Massa tumor - -
- Fenomena palatum Sulit dinilai Sulit dinilai
mole
Status Lokalis
Tenggorok
Pemeriksaan Orofaring
Rongga Mulut Hasil
Mukosa mulut Hiperemis (-), Edema (-), ulkus (-), massa (-)

Bibir Stomatitis (-), Lembab, hiperemis (-), krusta (-),


ulkus (-)
Lidah Hiperemis (-), Edema (-), atropi (-), ulkus (-),
gerakan segala arah
Gigi Lengkap, karies (-)

Kelenjar ludah Ptialismus (-)


Faring Hasil
Uvula Ditengah, hiperemis (-), edema (-), ulkus (-
), permukaan licin.
Palatum molle Hiperemis (-), edema (-), ulkus (-)
Palatum durum Hiperemis (-), edema (-), ulkus (-),
benjolan (-).
Tonsil Ukuran : T0 – T0 T0 T0
Hiperemis (-/-), kripta melebar (-/-),
detritus (-/-)
Dinding faring posterior Hiperemis (+), Edema (-)
Mukosa orofaring Hiperemis (+), edema (-), ulkus (-)
Diagnosis

• Faringitis akut

Tatalaksana

• Levofloxacin tab 500 mg 1x1


• Metilprednisolon (lameson) tab 8 mg
2x1 selama 3 hari
• Paracetamol (sanmol) tab 500 mg 3x1
• Ambroxol tab 30 mg 3x1
Definisi

Renner B., Mueller C., Shephard A., 2012, Environmental and Non-infectious Factors in
The Aetiology of Pharyngitis (Sore Throat), Department of Otorhinolaryngology,
Medical University of Vienna, Austria, Spingerlink, pp. 1041 - 1052
Etiologi

Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in Adults,
Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Etiologi

Weber R., 2014, Pharyngitis, Department of Family and Community Medicine,


University of Kansas School of Medicine-Wichita, 1010 North Kansas, USA, Elsivier,
pp 91-98
Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in Adults,
Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Etiologi

Dhingra PL, Dhingra S., 2014, Acute and Chronic Pharyngitis : In Diseases of Ear, Nose, & Throat and
Head & Neck Surgery, 6th ed., New York, Elsevier pp. 254
Dhingra PL, Dhingra S., 2014, Acute and Chronic Pharyngitis : In Diseases of Ear, Nose, & Throat and
Head & Neck Surgery, 6th ed., New York, Elsevier pp. 254
Etiologi

Dhingra PL, Dhingra S., 2014, Acute and Chronic Pharyngitis : In Diseases of Ear, Nose, & Throat and
Head & Neck Surgery, 6th ed., New York, Elsevier pp. 254
Etiologi (non-infeksius)

Renner B., Mueller C., Shephard A., 2012, Environmental and Non-infectious Factors in
The Aetiology of Pharyngitis (Sore Throat), Department of Otorhinolaryngology,
Medical University of Vienna, Austria, Spingerlink, pp. 1041 - 1052
Epidemiologi

Cots J., et al.,2015, Recommendations for Management of Acute Pharyngitis in Adults,


Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Epidemiologi

Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in Adults,
Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Epidemiologi

Murphy T., et al., 2013, Pharyngitis, Guidelines fot Clinical Care Ambulatory,
Michigan Medicine, University of Michigan
Patofisiologi

Mustafa M., et al., 2015, Pharyngitis, Diagnosis, and Embiric Antibiotic Treatment
Considerations, IOSR Journal of Dental and Medical Sciences, Vol. 14, Issue 5, PP.
110-116
Dhillon R. S., East C. A., 2000, Ear, Nose, and Throat and head and Neck Surgery,
Churchill Livingstone, London
Manifestasi Klinis

Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in Adults,
Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in
Adults, Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Manifestasi Klinis

Dhingra PL, Dhingra S., 2014, Acute and Chronic Pharyngitis : In Diseases of Ear, Nose, & Throat and
Head & Neck Surgery, 6th ed., New York, Elsevier pp. 254
Diagnosis

Murphy T., et al., 2013, Pharyngitis, Guidelines fot Clinical Care Ambulatory,
Michigan Medicine, University of Michigan
Diagnosis

Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in


Adults, Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Wessels M. R., 2011, Streptococcal Pharyngitis, The New England Journal of
Medicine, Boton pp. 364-355
Pemeriksaan Penunjang

Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in Adults,
Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Diagnosis

Dhingra PL, Dhingra S., 2014, Acute and Chronic Pharyngitis : In Diseases of Ear, Nose, & Throat and
Head & Neck Surgery, 6th ed., New York, Elsevier pp. 254
Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in Adults,
Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Murphy T., et al., 2013,
Pharyngitis, Guidelines fot Clinical
Care Ambulatory, Michigan
Medicine, University of Michigan
Tatalaksana

Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in Adults,
Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Tatalaksana

Weber R., 2014, Pharyngitis, Department of Family and Community Medicine,


University of Kansas School of Medicine-Wichita, 1010 North Kansas, USA, Elsivier,
pp 91-98
Terapi Simptomatis

Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in Adults,
Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Tatalaksana

Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in Adults,
Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
Tatalaksana

Murphy T., et al., 2013, Pharyngitis, Guidelines fot Clinical Care Ambulatory,
Michigan Medicine, University of Michigan
Tatalaksana

Dhingra PL, Dhingra S.,


2014, Acute and
Chronic Pharyngitis : In
Diseases of Ear, Nose,
& Throat and Head &
Neck Surgery, 6th ed.,
New York, Elsevier pp.
254
Levofloxacin

MIMS, 2018, Levofloxacin


Paracetamol

MIMS, 2018, Sanmol


Metilprednisolon

MIMS, 2018, Lameson


Ambroxol

MIMS, 2018, Ambroxol


Edukasi

Murphy T., et al., 2013,


Pharyngitis, Guidelines fot Clinical
Care Ambulatory, Michigan
Medicine, University of Michigan
Daftar Pustaka
 Cots J., et al., 2015, Recommendations for Management of Acute Pharyngitis in
Adults, Elsevier, Acta Otorrinolaringol, Spanyol, 66(3): 159-170
 Dhillon R. S., East C. A., 2000, Ear, Nose, and Throat and head and Neck Surgery,
Churchill Livingstone, London
 Dhingra PL, Dhingra S., 2014, Acute and Chronic Pharyngitis : In Diseases of Ear,
Nose, & Throat and Head & Neck Surgery, 6th ed., New York, Elsevier pp. 254
 Murphy T., et al., 2013, Pharyngitis, Guidelines fot Clinical Care Ambulatory,
Michigan Medicine, University of Michigan
 Mustafa M., et al., 2015, Pharyngitis, Diagnosis, and Embiric Antibiotic Treatment
Considerations, IOSR Journal of Dental and Medical Sciences, Vol. 14, Issue 5, PP.
110-116
 Renner B., Mueller C., Shephard A., 2012, Environmental and Non-infectious Factors
in The Aetiology of Pharyngitis (Sore Throat), Department of Otorhinolaryngology,
Medical University of Vienna, Austria, Spingerlink, pp. 1041 - 1052
 Weber R., 2014, Pharyngitis, Department of Family and Community Medicine,
University of Kansas School of Medicine-Wichita, 1010 North Kansas, USA, Elsivier,
pp 91-98
 Wessels M. R., 2011, Streptococcal Pharyngitis, The New England Journal of
Medicine, Boton pp. 364-355
Problem Initial Planning Planning Planning
Clue & Cue List Diagnosis Diagnosis Terapi Edukasi
Nn. N Menjelaskan
22 th 1. Faringi • DL Levofloxacin kepada pasien
- Nyeri
Sore dan keluarga
tenggorok throat tis akut • Swab 500mg 1x1
tentang:
- Batuk berdahak viral tenggorok Metilpredniso • Penyakit
- Dahak tidak lon 8 mg dan kondisi
2. Faringi
bisa keluar 2x1 pasien
- Demam sumer-
tis akut Paracetamol • Faktor
sumer bakteri 500mg 3x1 penyebab
- Faring hiperemi al Ambroxol 30 dari
mg 3x1 penyakit
pasien
• Terapi yang
diberikan
• Menghindar
i nyeri
tenggorok
• Meningkatk
an imunitas
tubuh
• Kontrol
setelah 1
minggu