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Corpal Nindya Duri Ikan nsr
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NIGHT SHIFT REPORTFriday, August 8th 2014Consultan on duty : dr. Nur Akbar A. SpTHT-KL (K)Chief on duty : dr. RadianDoctors on duty :- dr. Evy- dr. Nindya- dr.Fani
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Male, 53 years oldPatient was referred from Cimareme Clinic with WD/ Foreign Body fish bone in pharynx
CC: Ingested Fish BoneSince 3 hours before admitted to Hospital, while dinner he accidentally ingested fish bone. Pain on swallowing (-), Difficult to breath (-). difficulty on swallowing (-), vomiting (-), bloody cough (-). His family brought him to Cimareme Clinic and then reffered to Hasan Sadikin Hospital.
PHYSICAL EXAMINATIONGenerally State : Fully Allert , HR: 88x/m, RR: 20x/m, T : 36,7C Stridor : (-), Retraction (-)
Locally State : - Both ear: external auditory canal not hyperemic +/+, discharge -/-, cerument -/-, ear drum intact +/+, light reflex +/+, retroauricular, not hyperemic +/+- Nasal cavity : mucosa no hyperemic +/+, discharge -/-, inferior turbinate eutropy +/+, Deviasi septum (-), air passage +/+- OP : pharynx : not hyperemic, To: T1 T1 not hyperemic- MF : symmetric, no cranial nerve paralysis- Neck: no lymph node enlargement
Neck Soft Tissue X-ray
Laryngoscopy 900Tonsila Lingualis : 3rd Grade of Hyperthrophy, laceration (+)Epiglotica : eutrophyPlica Aritenoid : eutrophyPlica Vocalis: eutrophyPlica Piriformis : eutrophyPl. Ventrikularis : eutrophyTrachea: In the middleRima Glotis: openNo sign of Fish bone
WD/: Susp. Foreign body (fish bone) in the pharynx + LPR
ManagementLaryngoscopy 90 0Perform Neck Soft Tissue X-rayTh/ Cefixime 2 x 200 mg p.oMeloxicam 2x7,5 mg p.oLansoprazole 2 x 30 mg p.oEducation for LPRPlan to RLFO on 11-8-2014
THANK YOU