TUTORIAL KLINIK THT

RHINOSINUSITIS
Pembimbing : dr. Arin Dwi Iswarini, Sp.THT-KL., M.Kes

Oleh : Umbu Jabu Anggung Praing - 42170192

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IDENTITAS PASIEN
Nama : Ny. N
Nomor RM : 01-90-xx-xx
Tanggal Lahir : 07 September 1940
Usia : 79 tahun
Jenis kelamin : Perempuan
Alamat : Klitren lor - Gondokusuman
HMRS : 5 September 2019
Tanggal Pemeriksaan : 5 September 2019
KELUHAN UTAMA
NYERI KEPALA
ANAMNESIS
- RIWAYAT PENYAKIT SEKARANG

Pasien datang ke Poli THT RS Bethesda pada tanggal 5 September 2019, dengan keluhan nyeri kepala.
Keluhan dirasakan hilang timbul sejak 2 bulan yang lalu dan mengganggu kegiatan sehari-hari pasien.
Keluhan nyeri kepala berkurang jika minum obat dan dirasakan di daerah antara kedua alis dan kepala
belakang kiri.
Sebelumnya pasien mengeluhkan sering pilek namun sekarang sudah berkurang. Cairan yang keluar dari
hidung berwarna bening dan encer. Pasien mengatakan saat pilek biasanya tidak disertai batuk, hidung
terasa tersumbat. Namun tidak disertai dengan nyeri telinga ataupun cairan yang keluar dari telinga. Tidak
ada keluhan pendengaran, nyeri telan maupun suara serak. Keluhan demam, mual dan muntah disangkal
pasien.
Batuk lama : (-)
Alergi : (-)
Vertigo : (+)
Maag : (-)
Asma : (-)
Riwayat trauma : (-)
Hipertensi : (+) terkontrol
DM : (-)
Stroke : tahun 2009
Sakit gigi : (-)

RIWAYAT PENYAKIT DAHULU

Keluhan serupa : (-)

DM, Hipertensi, Alergi, Jantung, Cancer, Asma : (-)

RIWAYAT PENYAKIT KELUARGA

Riwayat Operasi :-

Riwayat Mondok : Saat stroke 10 tahun yang lalu

RIWAYAT PENGOBATAN
LIFE STYLE
- Pasien adalah adalah seorang ibu rumah tangga yang sehari-hari sering menghabiskan
waktunya untuk menyapu halaman rumah yang berdebu dan memiliki hobi untuk merajut
dan menjahit pakaian sendiri hingga larut malam.

- Pola makan pasien 3x sehari dengan lauk (ikan dll), sayur dan buah - buahan. Pasien
mengatakan sering mengkonsumsi es dan gorengan sejak usia muda.

- Pola tidur pasien tidak teratur.

- Pasien jarang berolahraga.

- Tidak ada riwayat merokok dan konsumsi alkohol.

PEMERIKSAAN FISIK
Keadaan Umum Tanda Vital
Tek. Darah : 130/80 mmHg
Baik
Respirasi : 18 x/menit
Nadi : 82 x/menit
Kesadaran Suhu : 36,6oC
Skala Nyeri :4
Compos mentis (E4V5M6)
Status Generalis
Kepala : Normochepali
Mata : Konjungtiva anemis (-/-), sklera ikterik (-/-), injeksi
konjungtiva (-/-), pupil isokor, reflek cahaya (+/+), gerakan
bola mata baik kesegala arah.
Hidung : Allergic shiner (-), allergic crease (-), allergic salute (-)
Mulut : Sesuai status lokalis
Telinga : Sesuai status lokalis
Leher : Limfonodi tidak teraba, nyeri tekan (-), pembesaran tyroid (-)

Thorax
Inspeksi : Dada simetris, kelainan bentuk dada (-), ketinggalan gerak (-)
Palpasi : Fremitus kanan-kiri normal, ictus cordis teraba di SIC 5 linea
midclavicularis sinistra
Perkusi : Sonor +/+, batas jantung normal
Auskultasi : Suara paru vesikuler(+/+), ronki (-/-), wheezing (-/-), suara
jantung S1 dan S2 reguler tunggal, bising (-)
Abdomen
Inspeksi : Tidak dilakukan
Auskultasi : Tidak dilakukan
Perkusi : Tidak dilakukan
Palpasi : Tidak dilakukan
Ekstremitas :
Atas : Akral teraba hangat, edema
(-) , CRT< 2 detik
Bawah : Akral teraba hangat, edema (-),
CRT < 2 detik
 STATUS LOKALIS (TELINGA)

Pemeriksaan Dextra Sinistra

Auricula Hiperemis (-), deformitas (-), edema (-), Hiperemis (-), deformitas (-), edema (-),
hematoma (-), nyeri (-) hematoma (-), nyeri (-)

Kelainan kongenital Tidak ada Tidak ada

Tumor Tidak ada Tidak ada
Nyeri tekan tragus Tidak ada Tidak ada
Planum mastoidium Nyeri tekan (-) Nyeri tekan (-)
Glandula limfatik Pembesaran (-) Pembesaran (-)
Can. Aud. Externa Serumen (+) 20%, Hiperemis (-), edema Serumen (+) 20%, Hiperemis (-), edema
(-), furunkel (-), otorrhea (-) (-), furunkel (-), otorrhea (-)

Membrana timpani Perforasi (-), Hiperemis (-), , Retraksi (-), Perforasi (-), Hiperemis (-), Retraksi (-),
Cone of light (+) arah jam 5 Cone of light (+) arah jam 7
 STATUS LOKALIS

Tes Garpu Tala Dextra Sinistra

Rinne + +
Weber Tidak ada lateralisasi Tidak ada lateralisasi
Scwabach Sama dengan pemeriksa Sama dengan pemeriksa
Telinga
Kesan: AD dan AS terdapat cerumen, tes garpu tala dalam batas normal
Pemeriksaan Dextra Sinistra STATUS LOKALIS (Hidung)
HIDUNG
Dorsum Nasi Deformitas (-), krepitasi (-), jejas (-), nyeri tekan (-)
Cavum Nasi Discharge (-) Discharge (-)
Rhinoskopi Anterior
Vestibulum Nasi Discharge (-), edema (-), hiperemis (-)
Septum Nasi Deviasi septum (-), perforasi (-)
Meatus Nasi Inferior
Edema (-), hiperemis (-),
Edema (-), hiperemis (-), discharge (-)
discharge (-)

Konka Inferior Hipertrofi (-), hiperemis (-)

Hipertrofi (-), hiperemis (-)

Hiperemis (-), polip (-), discharge (-),

Meatus Nasi Media Hiperemis (-), discharge (-), polip (-), edema (-)
edema (-)

Konka Media
Edema (-), hiperemis (-) Edema (-), hiperemis (-)

Rhinoskopi Posterior : Tidak dilakukan

 STATUS LOKALIS (Hidung)

SINUS PARANASAL
Inspeksi Eritem (-), edema (-) Eritem (-), edema (-)
Perkusi Nyeri ketok (-) Nyeri ketok (-)

Kesan : Tidak tampak deviasi septum dan tidak tampak hipertrofi konka
 STATUS LOKALIS (oropharynx)

CAVUM ORIS-TONSIL-FARING
Bibir Bibir sianosis dan kering (-), stomatitis (-)
Mukosa Oral Stomatitis (-), warna merah muda
Gusi dan Gigi Warna merah muda, karies dentis (-), ulkus (-)
Lingua Simetris, atrofi papil (-), lidah kotor (-), ulserasi (-)
Atap mulut Ulkus (-)
Dasar Mulut Ulkus (-)
Uvula Uvula tampak normal
Tonsila Palatina T2, hiperemis (-), detritus(-), T2, hiperemis (-), detritus(-),
permukaan tidak rata, kripta permukaan tidak rata, kripta
melebar (-) melebar (-)
Peritonsil Abses (-) Abses (-)
Faring Hiperemis (-), discharge (-)
Kesan : Cavum oris, tonsil dan faring dalam batas normal
Pemeriksaan Penunjang
- Tidak dilakukan
Diagnosis
Suspek Rhinosinusitis kronis
Diagnosis Banding
– Pilek dan hidung tersumbat

• Rhinitis Vasomotor

• Rhinosinusitis Kronis

• Rhinitis Alergi

– Nyeri kepala

• Cluster Headache

• Migrain
Penatalaksanaan
A. Farmakologi

Dekongestan Oral

- Pseudoefedrin tablet 30 mg 3x1

Analgetik

- Paracetamol tablet 500 mg 3x1 (bila nyeri)

B. Non Farmakologi

Edukasi
 EDUKASI

• Menjelaskan faktor risiko yang mendasari atau mencetuskan rhinosinusitis

kronis pada pasien
• Pencegahan timbulnya rekurensi
• Menghindari makanan yang dapat memicu sekresi mucus seperti makanan
pedas, minuman dingin
• Istirahat minimal 8 jam sehari
• Pemakaian obat sesuai dosis yang diberikan, paracetamol diminum bila
perlu saja. Apabila terdapat perburukan gejala yang mengganggu aktivitas
atau obat habis dapat kontrol ke dokter
 PLANNING

• Dapat dilakukan CT Scan Sinus Paranasal apabila gejala belum

membaik setelah mendapat terapi yang telah diberikan
• Rujukan ke spesialis THT apabila pasien tidak mengalami
perbaikan setelah pemberian terapi awal yang telah diberikan
termasuk pertimbangan untuk dilakukan bedah sinus endoskopi
fungsional untuk mengurangi gejala yang dialami.
PROGNOSIS

Ad vitam : Dubia ad bonam

Ad Fungsionam : Dubia ad bonam
Ad Sanationam : Dubia ad bonam
Thank you
Insiden
Di negara barat, batu empedu mengenai 10% orang dewasa. Angka prevalensi orang dewasa lebih tinggi di
negara Amerika Latin (20% hingga 40%) dan rendah di negara Asia (3% hingga 4%). Angka kejadian penyakit
batu empedu dan penyakit saluran empedu di Indonesia diduga tidak jauh berbeda dengan angka di Asia
Tenggara dan sejak tahun 1980-an agaknya berkaitan erat dengan cara diagnosis dengan ultrasonografi.

20-40% 10 % 3-4%

dewasa (Amerika Latin) negara barat Asia

KANDUNG EMPEDU
Definisi

- Tempat menyimpan cairan empedu dan

memekatkan cairan empedu yang dihasilkan hati

- Garam empedu menyebabkan meningkatnya k

elarutan kolesterol, lemak dan vitamin yang larut d
alam lemak --> bantu penyerapannya dari usus

- Hemoglobin yang berasal dari penghancuran sel

darah merah diubah menjadi bilirubin (pigmen utama
dalam empedu) dan dibuang ke dalam empedu
Etiologi
Eksresi garam empedu
01

Kolesterol empedu
02

Pigmen empedu
03

Infeksi
04
Faktor Risiko

Usia Jenis kelamin Berat badan (BMI)

> 40 tahun lebih cenderung
01 untuk terkena kolelitiasis
dibandingkan usia yang lebih
02 wanita > pria
03 BMI ↑ --> kolesterol ↑
muda

Nutrisi intra-vena
Makanan Aktifitas fisik
jangka lama
04 lemak (hewani) --> 05 ↓ kontraksi kandung 06 (-) stimulasi -->
kolesterol ↑
kontraksi kandung
empedu↓
empedu
DIAGNOSIS
Pemeriksaan Pemeriksaan
Anamnesis
fisik penunjang

1/2 - 2/3 tidak - batu kandung

Laboratorium Radiologi
ada keluhan empedu
- peradangan - Foto polos
- dispepsia (intoleran - batu saluran akut --> abdomen
makanan berlemak)
empedu leukositosis - USG
- bilirubin ↑ -->
- nyeri epigastrium
(kuadran kanan atas - Kolesistografi
atau perikondrium) batu di duktus - CT - Scan
- nyeri
antasid
↓ dengan koledokus
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