Case Report

Day/ Date : Monday / July 1st 2017

Doctors on duty : Eko/Rian/Faisal-Loren-Desy
Consultant : Al Hafiz MD, ORL

Department of Otorhinolaryngology Head and Neck Surgery

Faculty of Medicine Andalas University/Dr. M. Djamil Hospital
Padang
 Identity of Patient
Female, 31 year old

Chief Complaint
Difficulty in swallowing getting severe since 1
day before admission
 Medical History
Difficulty in swallowing getting severe since 1 day
before admission
Previously, patient felt pain in swallowing and fever 1
week ago patient has got medication from general
practitioner , after that patient went to ENT Specialist
and suggested to dr M. Djamil Hospital
 Medical History
Patient can eat moist meals, and drink a little
There was pain and difficulty in opening the mouth
since 1 day ago
There was muffled voice since 2 days ago
There was history of toothache
There was history of recurrent pain on swallowing
There was no droolling
There was no pain and no neck stiffness
 Medical History
There was no saliva mixed with pus
There was no difficulty in breathing
There was no hoarseness
There was no history fish bone stuck in the throat
There was no history of diabetic mellitus
There was no history of hypertension before
There was no cough and cold
 General Examination
General condition was moderately ill, compos mentis
cooperative

BP : 110/70 mmHg
RR : 20 x/min
PR : 92 x/min
T : 36.70C
 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 wide, inferior turbinate was
eutrophy, middle turbinate was eutrophy, discharge
(-), septal deviation (-)
Left nasal cavity :
Nasal cavity was wide, inferior turbinate was
eutrophy, middle turbinate was eutrophy, discharge
(-), septal deviation (-)
 ENT Examination
Oral Cavity :
Trismus (+) 2cm, caries
(+) at teeth no 17
Oral hygyne : poor
 ENT Examination
Throat :
Pharyngeal arch was asymmetric,
left peritonsilar region edema
(+), hyperemic (+), fluctuative (+),
uvula pushed to inferior and
right side, right tonsil T1
hyperemic (-), left tonsil difficult
to evaluate, hyperemic (+),
posterior pharyngeal wall
difficult to evaluate
 Aspiration
Peritonsil region
 Diagnosis
Working Left Peritonsilar abscess
Diagnosis

ICD X Peritonsilar abscess ( J.36)

 Management
Planned to perform incision & exploration abscess
under local anesthesia
Informed consent patient and family was agree
Therapy:
IVFD RL 8 hours/kolf
Ceftriaxone 2 x 1 gr (iv) skin test
Metronidazole drip 3 x 500 mg (iv)
Povidone iodine gargle
 Operating Report
Patient was lying down in operating table in general
anesthesia
Aseptic and antiseptic procedure in the operation
field
Performed incision in peritonsil area in the fluctuatife
area, pus (+) and widened area with clamp
superiorly, inferiorly, medially and laterally.
Irrigation with Nacl 0,9 % + povidone iodine
Operation finished
 Post Operation Instruction
Evaluation vital sign
Evaluation bleeding from the incision wound
Evaluation chest pain and difficulty in breathing
 Post Operation Instruction
Th/ post operation:
- IVFD RL 0,9 % + drip tramadol 8 hours/kolf
Ceftriaxone 2 x 1 gr (iv) skin test
Metronidazole drip 3 x 500 mg (iv)
Povidone iodine gargle 3x1 cup
THANK YOU