CASE DISCUSSION

SINUSITIS

Supervisor dr. H. Oscar Djauhari, Sp. THT-KL

Presentants Marcella Aprilia Lonatrista 2010.061.150 Arga Aditya 2008730006

Otolaryngology, Head and Neck Department Medical Faculty of Unika Atma Jaya Medical Faculty of Muhammadiyah Jakarta University Syamsudin, S.H. Regional General Hospital, Sukabumi 26th November 2012 29th December 2012

CASE DISCUSSION
A. PATIENTS IDENTITY Name Gender Age : Ms. I : Female : 28 years old

Occupation : employer Address : Sukabumi

B. HISTORY Chief Complaint : recurrent cold since 4 months before admission

Additional Complaints : headache, located at the base of the nose History of Present Illness A 28-year old woman came to ENT department at Syamsyudin hospital with a chief complaint of recurrent cold at the morning since 4 month before admission. The nose discharge had yellowish geen colour and smelled odour since 1 month before admission. She also complained had nasal speech. Fever and cough were denied. She had taken over the counter medication but she hadnt feel any improvement. No complainded on eyes.

History of Past Illness History of right nose trauma three times since 11 years ago History of hypertension was denied

History of Family Illness History of family illness was denied Habits Recurrent cold Does not smoke Does not drink any alcohol substance. Does not use any routine medication. Does not use any narcotics.

C. PHYSICAL EXAMINATION
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General condition : Appear calm Body weight Height Blood pressure Pulse Respiratory rate Temperature : 45 kg : 156 cm : 110/90 mmHg : 80 beat per minute : 22 times per minutes : 36 oC

ENT Examination Ear Right ear - Auricle : normal - External auditory canal: hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) , cerumen (-) - Tymphanic membrane: Intact, hyperemic (-), retraction (-), light reflex (+)

Left ear - Auricle : normal - External auditory canal: hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) , cerumen (-) - Tymphanic membrane: Intact, bulging (-), light reflex (+) Rinne test : air conduction is being louder or louder than bone conduction on both ear o Weber test o Schwabach test : no lateralization : same with examiner on both ear

Nose Right nose - Mucous membrane: hyperemic (+), edema (+), secretion (+), mass (-), laceration (-), crust (-)
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- Inferior conchae : eutrophy - Septum - Air passage Left nose - Mucous membrane: hyperemic (+), edema (-), secretion (+), mass (-), laceration (-), crust (-) - Inferior conchae : eutrophy - Septum - Air passage : no deviation : normal : no deviation : decreased

Oropharynx - Posterior pharynx : hyperemic (-) - Palatine tonsils - Uvula - Dental : T1 / T1, hyperemic (-), detritus (-) : symmetrical : no abnormatlities

Maxillofacial : symmetrical Neck : no lymphadenopathy

D. WORKING DIAGNOSIS Sinusitis

E. DIFFERENTIAL DIAGNOSIS Allergic sinusitis

F. WORK-UP Laboratory: 1. Routine blood count 2. Liver function test 3. Blood glucose test 4. Renal function test 5. Bleeding time- clotting time

Roentgen thorax PA Waters X-ray ECG

G. TREATMENT Antral Wash Out dextra Ceftriaxone 2 x 1 gram vial Ketorolac 3 x 1 ampul (@30 mg/ml) Tranexamic acid 3 x 2 ampul (@ 250 mg/ml)

Examination Hemoglobin Leucocyte count Hematrocryte Thrombocyte SGOT/ASAT SGPT/ALAT Ureum Creatinine

Normal value 12 -16 g/dl 4000 9000 / ul

11/9/2012 12,9 10.100

25/11/2012 11,9 7600 36,1 262.000

< 31 U/L/37 C < 36 U/L/37 C 20 -40 mg/dl

22,0 18,3 24,3

< 0.9 mg/dl -1.1 mg/ 0,7 dl

Bleeding time Clotting time Blood glucose

1-3 minutes 1-11 minutes < 180 mg/dl

2 minutes 6 minutes 86

1 minute 6. 30 minutes 108

X-ray 1/11/2012: waters position

Right antrum wall thickened Opaque cloaking seen at right maxillary sinus Resume: sinusitis maxillary particularly dextra

chest x-Ray 11/9/2012: cor & pumo normal

ECG 25/11/2012 : within the normal limit

Follow up 26/11/2012 S: cold, pain at the forehead especially when she bows O: Nose Right nose - Mucous membrane: hyperemic (+), edema (+), secretion (+), mass (-), laceration (-), crust (-) - Inferior conchae : eutrophy - Septum - Air passage Left nose - Mucous membrane: hyperemic (+), edema (+), secretion (+), mass (-), laceration (-), crust (-) - Inferior conchae : eutrophy - Septum - Air passage A: sinusitis : no deviation : normal : no deviation : decreased

26/11/2012 3.15 pm S: Patient awake 2 hours after AWO. Patient feel sore on the right nose, headache, nausea, blood taste inside the mouth, dry lips and thirsty O: tampon on right nose A: post-op sinusitis maxillaris dextra (AWO)

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