CASE DISCUSSION

SINUSITIS

Supervisor

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

PresentantsMarcella Aprilia Lonatrista 2010.061.150Arga Aditya 2008730006

Otolaryngology, Head and Neck DepartmentMedical Faculty of Unika Atma Jaya

Medical Faculty of Muhammadiyah Jakarta UniversitySyamsudin, S.H. Regional General Hospital, Sukabumi

26th November 2012 – 29th December 2012

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CASE DISCUSSION

A. PATIENT’S IDENTITY

Name : Ms. I

Gender : Female

Age : 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 hadn’t 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

2

General condition : Appear calm

Body weight : 45 kg

Height : 156 cm

Blood pressure : 110/90 mmHg

Pulse : 80 beat per minute

Respiratory rate : 22 times per minutes

Temperature : 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 : no lateralization

o Schwabach test : same with examiner on both ear

Nose

Right nose

- Mucous membrane:

3

hyperemic (+), edema (+), secretion (+), mass (-), laceration (-), crust (-)

- Inferior conchae : eutrophy

- Septum : no deviation

- Air passage : decreased

Left nose

- Mucous membrane:

hyperemic (+), edema (-), secretion (+), mass (-), laceration (-), crust (-)

- Inferior conchae : eutrophy

- Septum : no deviation

- Air passage : normal

Oropharynx

- Posterior pharynx : hyperemic (-)

- Palatine tonsils : T1 / T1, hyperemic (-), detritus (-)

- Uvula : symmetrical

- Dental : 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

4

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)

5

Examination Normal value 11/9/2012 25/11/2012

Hemoglobin 12 -16 g/dl 12,9 11,9

Leucocyte count 4000 – 9000 / ul 10.100 7600

Hematrocryte 36,1

Thrombocyte 262.000

SGOT/ASAT < 31 U/L/37 C 22,0

SGPT/ALAT < 36 U/L/37 C 18,3

Ureum 20 -40 mg/dl 24,3

Creatinine < 0.9 mg/dl -1.1 mg/

dl

0,7

Bleeding time 1-3 minutes 2 minutes 1 minute

Clotting time 1-11 minutes 6 minutes 6. 30 minutes

Blood glucose < 180 mg/dl 86 108

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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

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ECG 25/11/2012 : within the normal limit

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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 : no deviation

- Air passage : decreased

Left nose

- Mucous membrane:

hyperemic (+), edema (+), secretion (+), mass (-), laceration (-), crust (-)

- Inferior conchae : eutrophy

- Septum : no deviation

- Air passage : normal

A: sinusitis

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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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