Scenario A

Case of Scenario
• A 7 year old boy brought by his mother to Puskesmas because
there is a mass on the lower right neck and getting worse over 4
days. The mass started as a small lump that has enlarged ti the
sized of the marbel and now is becoming paintful, and warm to
touch with overlying redness. Also there is difficulty to move his
neck. Since 7 days ago, he has had a fever , runny nose, cought
and sore throst, also complaining of a swallowing foods and
drinking fluids. No choicealternate. His mother give him a
medicine, but the fever going down but then up again.
• His past medical history : never has complaint like this before.
• Family history : no one has the same complaint.
• Immunization history : basic immunization are complete.
• Growth and development history : normal
• Diet history : same like common children.
• Physical examination :
• Vital sign : BP 90/60 mmHg, P 98x/m regular, RR 24x/m, T 37,6o C.
• Spesific examination :
• Head : pupils are equal and reactive. Sclera is white and conjunctiva are clear.
Pharynx is hyperemic. Both tonsil T3-T3, erythematous with patches of exude.
• Neck (Regio colli anterolateral inferior dextra) :
• -Inspection : a mass with underlying erythema
• -Palpation : a warm mass, size 2cm of diameter, tender, pain but no
fluctuance.
• Thorax : Cor/heart normal, no murmurs. Pulmo/lungs normal.
• Abdomen : Normal, no hepatospenomegaly.
• Extremities : normal. Warm. Capillary refill time of one second.
•
• Laboratory : Hb 12 mg/dl. WBC 16.000/mm3. Rate of sedimentation blood 10
mm/h.
Term Clarification
 Problem Identification
1. A 7 year old boy brought by his mother to Puskesmas because there
is a mass on the lower right neck and getting worse over 4 days. The
mass started as a small lump that has enlarged to the sized of the
marbel and now is becoming paintful, and warm to touch with
overlying redness. Also there is difficulty to move his neck.

2. Since 7 days ago, he has had a fever , runny nose, cought and sore
throst, also complaining of a swallowing foods and drinking fluids.
No voice alternate. His mother give him a medicine, but the fever
going down but then up again.
– His past medical history : never has complaint like this before.
– Family history : no one has the same complaint.
– Immunization history : basic immunization are complete.
– Growth and development history : normal
– Diet history : same like common children.
3. Physical examination :
– Vital sign : BP 90/60 mmHg, P 98x/m regular, RR 24x/m, T 37,6o C.
– Spesific examination :
– Head : pupils are equal and reactive. Sclera is white and conjunctiva are clear.
Pharynx is hyperemic. Both tonsil T3-T3, erythematous with patches of exude.
– Neck (Regio colli anterolateral inferior dextra) :
– -Inspection : a mass with underlying erythema
– -Palpation : a warm mass, size 2cm of diameter, tender, pain but no
fluctuance.
– Thorax : Cor/heart normal, no murmurs. Pulmo/lungs normal.
– Abdomen : Normal, no hepatospenomegaly.
– Extremities : normal. Warm. Capillary refill time of one second.

4. Laboratory : Hb 12 mg/dl. WBC 16.000/mm3. Rate of sedimentation blood

10 mm/h.
 Problems Analysis
1. a. What is anatomy of the neck based on case?
• Answer :
• Organs :
• Laryngopharynx: the posterior surface of the laryngx extends from the upper edge of the
epiglottis down the cartilago cricoidea.
• Larynx: a special organ that has a protective sphincter at the air entrance and sound. Above the
larynx opens in the laryngopharynx, under the larynx continuing the trachea. Laryngx formed 9
cartilages connected by the cracking and ligament of cartilago thyroidea, cricoidea, arytenoidea,
corniculata, cuneiformis, and epiglottis
• Trachea: 1-2 tracheal rings from the lower edge of cartilago cricoidea (confronted with a
corpus vertebra cervicalis VI).
• Oesophagus: ranging from as high as cartilago cricoidea, posterior tracheal surface as high as
corpus vertebra cervicalis VI
• Grandula thyroidea: endocrine organ in the neck consisting of two lobes dextra et sinistra
linked by isthmus containing thyroid hormone. This cloaking organ is attached to the larynx and
trachea. The upper limit of the thyroidea cartilage, its base lies below the height of the IV-V
tracheal ring.
• Grandula parathyroidea: oval endocrine organ there are four pieces closely related to the
posterior edge of the thyroidea gland
• Lymphonodus: the lymphoid organ microscopic structure of its oval shape lies along the
lymph vessels, the normal diameter beberaoa millimeter to 2 cm, surrounded by a capsule of
connective tissue arranged cortex, parakorteks and medulla, usually obtained in groups and
associated with the lymphatic flow from certain regions or organs(Snell, 2012).
 What cause a lump in the neck?
1.Increased lymphocytes and macrophages
during reaction to the antigen.
2.Infiltration by inflammatory cells in infections
that attack the lymph glands
3.The presence of infiltration of lymph glands by
macrophages containing metabolites
(Isselbacher, 2012).
 What is fisiology and histology of the
specific organ?
• Histology
Lymph node structure that shows the structure of lymph nodes
•
structuredivided into three main parts: the cortex, the cortex, and the medulla.

• Physiology
1. Lymph nodes are an important part of the body's defense mechanism that is
spread throughout the body, along the path of the lymphatic vessels. Lymph
nodes are most common in the inguinal and axilla regions.
2. Lymphonodies function to filter out lymph fluids and phagocytosis of bacteria or
foreign substances from lymphatic fluids. Macrophages are in the reticular fiber
webbing of each node. Thus, when the lymph fluid is filtered, the nodules play
a role of localization and prevent the spread of infection into the general
circulation.
3. Limfonoduli also make, store, and megalirkan B lymphocytes and T lymphocytes.
B lymphocytes collect in limpoit limpoit nodules, whereas T lymphocytes collect
under the nodule in the parakortek sorcorti calareas.
4. Lymphonoduli are also a site of antigen recognition and activation of antigenic B
lymphocytes that produce plasma cells. Plasma cells then make and remove
specific antibodies against certain antigens into the blood and lymph vessels
(Guyton, 2007).
 What is the meaning of the mass started as a small
lump that has enlarged to the sized of the marbel
and now is becoming paintful, and warm to touch
with overlying redness?

• The meaning is that the child has lymphadenitis, where the

characteristic of lymphadenitis are enlarged lymph nodes with
size more than 1 cm and has inflammantory’s sign such as
painful, warm and with overlaying redness (Price and Wilson,
2006).
What is the relation of age and gender
in this case?
• There is no relation of gender, but age. The age of the boys is
related to his complaint because these symptoms are often
found in children especially those associated with pharyngitis
that caused by infection (Marcdante, Karen J. dkk., 2003).
What is patofisiology of the mass started as a lump that
has enlarged of the size of a marble?

Infection of microorganism  inhalation of droplets

 bacteria reach the alveoli  microorganisms in
phagocytes by macrophages  microorganisms
survive and multification in macrophages  the
occurrence of dissemination through limfogen 
regional Lymph glands hilar  inflammatory to
regional lymph (lymphadenitis)  lump  there’s no
treatment  invasion and infection of
microorganisms continues  inflammatory continues
to extend  the lump was further enlarged (Price,
dan Wilson, 2006).
What is the meaning he is difficult to move his neck?
The lump grow bigger than usual and followed by an
imflamation mark (Limfadenitis) such as pain, erythema that
can make he difficuly to move his neck.

What is the organ that can grow abnormality in the neck?

• Tonsil : lymphatic ring-shaped tonsils are not intact around

the entrance of the mouth and nose to the pharynx
• Lymph Nodes : lyphataic nodes can be found all over the body
and located along the lymph vessels. lymphaticus node
function is as filter. any foreign body or bacteria trapped in
the lymph nodes when the lymph diffuses slowly through
reticocyte fibers (Snell, 2012).
2. a. What is the meaning that he has had a fever, runny nose, cought and
sore throst, also complaining of a swallowing foods and drinking fluids.
No voice alternate?

He has had a fever, runny nose, coughand sore throst, also complaining of a
swallowing foods and drinking fluidsits means that the boy was infected by
pathogen, and also seen by number of leukocytes that abnormal, both of
tonsil T3-T3. And tonsil T3-T3 mean the boy suffered tonsillitis.
 What is patofisiology of the fever, runny nose, cough and sore
throat, also complaining of swallowing foods and drinking fluids?

Fever :
• Infection by antigen to the regional lymph nodes in the hilus  an
inflammatory reaction along the lymph nodes (lymphangitis) and regional
lymph nodes (lymphadenitis)  stimulates pyrogen release (IL-1, IL-6,
TNF-, IFN)  triggers acid release arachidonat synthesis PGE1 set point
thermoregulator metabolic activity fever subfebris (Harisson,
dkk.,2012).
Runny nose, cough and sore throat :
• Virus/bacteria  infection of ephitelial cells of nasal passages sore
throat airway receptor irritation  cholinergic stimulation  mucus
secretion runny nose (Price, and Wilson, 2006).
• Virus/bacteria  infection of ephitelial cells of nasal passages  sore
throat  airway receptor irritation  cholinergic stimulation 
broncoconstruction cough (Price, dan Wilson, 2006).
Swallowing foods and drinking fluids :
• Pathophysiology of tonsillitis: the presence of recurrent infections in the tonsils
then at a time the tonsils can not kill all germs so that the germs then infect the
tonsils. In this state the body's defense function of the tonsils turns into a place of
infection. And one day germs can spread throughout the body for example when the
state of the body decreased. The outer antigen, contact with the tonsil surface will
be bound and carried by mucosal cells (M cells), antigen presenting cells (APCs),
macrophage cells and dendritic cells found in tonsils to Th cells in germinativum
centers. Then this Th cell will release the mediator that will stimulate the B cells. B
cells form immunoglobulin (Ig) M pentamer followed by IgG and IgA formation.
Some B cells become memory cells. Immunoglobulin (Ig) G and IgA will passively
diffuse into the lumen. When low antigen stimulation will be destroyed by
macrophages. If high concentration of antigen will cause cell proliferation response
of B at germinativum centrum so it is sensitized to antigen, causing cellular cell
hyperplasia tonsil T3-T3  tonsil reachcenter line betweenuvula and pillaers
posterior Swallowing foods and drinking fluids.
• What is the meaning his mother give medicine, but the fever ging down
but then up again?
• Answer :
• That means, his mother just gave him an antipyretic drug to down the fever,
but the boy also infected by bacteria/virus seen from the number of
leukocytes that abnormal that can cause a fever again. So the boy also
needs anti-microorganisms to eliminate the infection.

• What is relation of this supportive factor and the disease?

• Answer :
– Immune response to infective agents (eg, bacteria, viruses, fungi).
– Inflammatory cells in infections involving the lymph node.
– Infiltration of neoplastic cells carried to the node by lymphatic or blood
circulation (metastasis).
– Localized neoplastic proliferation of lymphocytes or macrophages (eg,
leukemia, lymphoma).
– Infiltration of macrophages filled with metabolite deposits (eg, storage
disorders) (William, K. 2017).
What is the interpretation of the
physical examination?
 How is the patofisiology of the abnormal physical
examination?

• Infection by antigen to the regional lymph nodes in the

hilus  an inflammatory reaction along the lymph nodes
(lymphangitis) and regional lymph nodes (lymphadenitis) 
stimulates pyrogen release (IL-1, IL-6, TNF-, IFN)  triggers
acid release arachidonat synthesis PGE1 set point
thermoregulator metabolic activity fever subfebris
(Harisson, dkk.,2012).
What is the interpretation of the
specific examination?
 How is the patofisiology of the
abnormal specific examination?
• With infection pharyngitis, bacteria or viruses may directly
invade the pharyngeal mucosa, causing a local inflammatory
response. Other viruses, such as rhinovirus and coronavirus,
can cause irritation of pharyngeal mucosa secondary to nasal
secretions (Accera, J., 2010).
What is the interpretation of the
Laboratory ?
 How is the patofisiology of the
Laboratory ?
• Leukocytosis :
• Infeksi Patogen (bakteri/ virus) → antigen spreads
lymphogenically to the nearest lymph tissue → inflammation
of the lymph nodes (neck) → leukocyte cells migrate to the
inflammatory region → an increase in leukocytes as a respon.
 How to diagnose ?
Anamnesis
• A 7 year old boy brought by his mother to Puskesmas because there is a mass on the
lower right neck and getting worse over 4 days.
• lump that has enlarged ti the sized of the marbel and now is becoming paintful, and
warm to touch with overlying redness
• fever , runny nose, cought and sore throst, also complaining of a swallowing foods and
drinking fluids
Physical examination
• T 37,6o C.
• Pharynx is hyperemic. Both tonsil T3-T3, erythematous with patches of exude.
• Neck (Regio colli anterolateral inferior dextra) :
• -Inspection : a mass with underlying erythema
• -Palpation : a warm mass, size 2cm of diameter, tender, pain but no fluctuance.

Laboratory
• WBC 16.000/mm3
• What are the Different Diagnose (DD) ?
• Answer :
• Tonsilofaringitis
• Infiltrat tonsil
• Limfoma
• Tumor tonsil
• Mumps
• (Panduan Praktik Klinis Bagi Dokter di Fasilitas
Pelayanan Primer, 2014)
•
• What is the Supporting examination?
• Answer :
• 1. Full blood examination.
• 2. Microscopic examination with Gram staining.
• 3. On suspicion of fungal infection, can be done
with microscopic examination of pharyngeal
mucosal swab with KOH stain.
• 4. Swab tonsils for microscopy examination with
Gram staining.
Working diagnose
• Lymphadenitis et cause tonsilofaringitis.
Plan
• 1. Prevention by maintaining health and body hygiene can
• helps prevent various infections.
• 2. To help reduce pain, affected lymph glands can be warmly compressed.
• 3. The management of KGB neck enlargement is based on the cause.
- Causes by the virus may heal itself and require no treatment other than
observation.
- Treatment of bacterial KGB infection (lymphadenitis) is a 10-day oral
antibiotic with monitoring within the first 2 days of flucloxacillin 25 mg / kgBB
four times daily. If there is an allergic reaction to penicillin-class antibiotics
cephalexin may be given 25 mg / kg (up to 500 mg) three times daily or
erythromycin 15 mg / kg (up to 500 mg) three times daily.
- If the cause is Mycobacterium tuberculosis then given anti tuberculosis drugs.
- Usually if the infection has been treated, the gland will shrink slowly and the
pain will disappear. Sometimes the enlarged glands remain hard and no longer
feel soft on the palpation.
• (Panduan Praktik Klinis Bagi Dokter di Fasilitas Pelayanan Primer, 2014)
Complication
• Abses peritonsilar, Abses retrofaringeal, Gangguan fungsi tuba
Eustachius, Otitis media acute, Sinusitis, Laringitis, Epiglotitis,
Meningitis, Glomerulonefritis acute, Demam rematik acute,
Septikemia
(Panduan Praktik Klinis Bagi Dokter di Fasilitas Pelayanan Primer,
2014)

Prognosis
• Ad vitam : Bonam
• Ad functionam : Bonam
(Panduan Praktik Klinis Bagi Dokter di Fasilitas Pelayanan Primer,
2014)
 General doctor competency
• Level Ability 4: diagnose, perform self-
management and complete
• 4A. Competencies achieved at the time of
graduation
• Able to make clinical diagnoses based on physical
examination and additional checks requested by
a doctor (eg simple laboratory examination or X-
ray). Doctors can decide and be able to handle
the problem independently to complete (Konsil
Kedokteran Indonesia, 2012).
• NNI
• "The parable of the muslims believers in love,
loving and caring among them is like one
body; when one organ feels sick, then the
whole body responds with a fever. "(HR.
Muslim)
 Conclusion
• A 7 year old boy brought by his mother to Puskesmas
because there is a mass on the lower right neck, he
has had a fever , runny nose, cought and sore throst,
also complaining of a swallowing foods and drinking
fluids because lymphadenitis et causa
tonsilofaringitis.
Conceptual Framework