Case Report

Day/ Date : Sunday/ May 29th 2016

Doctors on duty : Delva/ Erwi-Anto-Suci/Faisal
Consultant : Fachzi Fitri, MD, ORL, MARS

Department of Otorhinolaryngology Head and Neck Surgery

Faculty of Medicine Andalas University/Dr. M. Djamil Hospital
Padang
 Identity of Patient
Female, 35 year old

Chief Complaint
Bleeding from the right nostril 2 hours before
admission
 Medical History
Bleeding from the right nostril 2 hours before admission.
Previously the patient was watching television, suddenly
there was bleeding from right nostril about a half
teaspoon and stop spontaneuosly, then the patient came
to M. Djamil hospital.
There was history of scracthing the nose before
There was no nasal obstruction and post nasal drip
There was no fullness sensation on the cheek
there was no disturbance of smell
 Medical History
There was no fullness sensation at the ear
There was no decrease of hearing
There was no double vision
There was no history of gum bleeding and prolonged
bluish skin after trauma
There was no history of trauma at the nose
There was no history of sneezing more than 5x if
contact with dust or cold
 Medical History
There was no history of diabetic mellitus and
hypertension
There was no history of consuming medicine such as
aspilet for long period
There was no fever, cold and cough
 General Examination
General condition was moderately ill, compos mentis
cooperative
PR :88x/min
RR :18 x/min
T :36,60 C
BP : 120/70

Eye : conjunctiva was not anemic

 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:
Right Nasal Cavity
Nasal cavity was narrow, inferior turbinate was edema,
middle turbinate couldn't be evaluated, clotting (+),
active bleeding (-), septal deviation (+) cryst, there was
hyperemic at Kiesselbach area, discharge (-)
Left Nasal Cavity
Nasal cavity was wide, inferior turbinate was eutrophy,
middle turbinate was eutrophy, clotting (-), active
bleeding(-), septal deviation(-), discharge (-)
 ENT Examination
Throat
Pharyngeal arch was symmetric, uvula in the midline,
tonsil T1-T1 not hyperemic, pharyngeal posterior wall
clotting (+), active bleeding (-)
Nasoendoscopy
 Nasoendoscopy
Right nasal cavity Left nasal cavity
Nasal cavity Narrow Wide
Inferior turbinate Edema Eutrophy
Colour of Inferior Turbinate Hyperemic (-) Hyperemic (-)
Middle turbinate Eutrophy Eutrophy
Colour of Middle Turbinate Hyperemic (-) Hyperemic (-)
Middle meatal Open Open
Discharge (-) (-)
Crust - -
Septal Deviation (+) cryst, contact Deviation (+) cryst,
point (-) , hyperemic (+) contact point (-)
Nasopharynx Mass(-)
 Laboratory Findings
Haemoglobin :13,1 gr/dl
Leukocyte : 6.700/mm3
Thrombocyte : 309.000/mm3
Ht : 38 %
PT : 9,2 second
APTT : 36,7 second

Result : In normal limit

 Working Diagnosis
Diagnosis -Post anterior epistaxis
caused by mechanical trauma
-septal deviation

ICD 10 - Epistaxis (R 04.0)

- Septal deviation( J34.2)
 Management

Th/ Applied chloramphenicol ointment

Education
Control to ENT HNS out patient clinic if there is any
complain