CASE PRESENTATION EAR, NOSE, THROAT, HEAD AND NECK DEPARTMENT

SYAMSUDIN, SH HOSPITAL, SUKABUMI

Supervisor: dr. H. Oscar Djauhari, Sp.THT-KL
Created by: M.Khalif Ranroe, Rizka Farhani, Winda Fauti
University of Muhammadiyah Jakarta

R.

Male, 7 th years old, has Earache

a. Identity
Name

: An. A

Age

: 7 years old

Sex

: Male

Tribes

: Sundanesse

Address

: Siliwangi

b. History

Chief complaint

Additional complaint :

earache in the right ear since yesterday

Cough, cold, fever, and cannot hear clearly.

History of present illess :

Since 4 days ago, the patient complained of cough, colds, and fever. Since
3 days ago, so cough up phlegm green. Since then, secretions from the
nose also become yellowish green. Last night, high fever, the patient can
not sleep, and said that his right ear pain. There was no fluid or blood from
the right ear. Hearing to be not as clear as previous.
Past medical history :
The patient denies any lung disease previously.
-

The patient had history of recurrent cold 3 times in the last year.

Allergy (-)

History of earache before (-)

Habit of cleaning the ear (-)

History of trauma (-)

CASE PRESENTATION EAR, NOSE, THROAT, HEAD AND NECK DEPARTMENT

SYAMSUDIN, SH HOSPITAL, SUKABUMI
Supervisor: dr. H. Oscar Djauhari, Sp.THT-KL
Created by: M.Khalif Ranroe, Rizka Farhani, Winda Fauti
University of Muhammadiyah Jakarta

R.

c. Physical Examination
General State
General condition : Severe illness
Conciousness

: Compos mentis

Blood pressure

: 110 / 80 mmHg

Heart rate

: 100 beats per minute

Respiratory rate

: 22 beats per minute

Temperature

: 38,8 C

Weight

: 25 kg

Ear, Nose, Throat, Head and Neck State

Ears

: Auricle
External Acoustic Canal

: normal / normal
:

Edema

: -/-

Hyperemic

:-/-

Secret

:-/-

Cerument

:-/-

Foreign body

:-/-

Tympanic Membrane

Cone of Light

: +/+

Hyperemic
Retraction
Bulging
Perforation
Tuning Fork Tests
Rinne
Weber
Schwabach

:-/:-/:+/+
:-/-

Palpation
Preaurikular
Retroaurikular

:-/+
: Lateralization to the right / Lateralization to the right
: Lengthened / Normal

: Tragus tenderness -/: Tenderness -/-

CASE PRESENTATION EAR, NOSE, THROAT, HEAD AND NECK DEPARTMENT

SYAMSUDIN, SH HOSPITAL, SUKABUMI
Supervisor: dr. H. Oscar Djauhari, Sp.THT-KL
Created by: M.Khalif Ranroe, Rizka Farhani, Winda Fauti
University of Muhammadiyah Jakarta

Nose

:
External nose

: no deformity

Nasal septum

: no deviation

Mucosa

: Colour

: pink/pink

Hyperemic

: -/-

Discharge

: + green / + green

Concha

: eutrophy / eutrophy

Nasopharynx Oropharynx:
Uvula

: at the middle

Mucosa of pharynx : not hyperemic / not hyperemic

Tonsil

: size T1 / T1, not hyperemic / not hyperemic

Face :
Inspection
Symmetric
Swelling -/Tenderness -/-

Neck :
Inspection : Mass (-)
Palpation : Lymph node enlargement (-)
Thyroid enlargement (-).

Thorax :
Inspection : symmetric chest movement
Palpation : right stem fremitus = left stem fremitus
Percussion : ??? mau nulis normal tp bingung cara nulisnyaa
Auscultation

: ronchi - / - , wheezing - / -

d. Working Diagnosis : Supurasi Stage of Acute Otitis Media of the right ear
Acute Rhinitis

R.

CASE PRESENTATION EAR, NOSE, THROAT, HEAD AND NECK DEPARTMENT

SYAMSUDIN, SH HOSPITAL, SUKABUMI
Supervisor: dr. H. Oscar Djauhari, Sp.THT-KL
Created by: M.Khalif Ranroe, Rizka Farhani, Winda Fauti
University of Muhammadiyah Jakarta

R.

e. Differential Diagnosis
Otitis Eksterna
Otitis media serosa acute

f. Additional Examination :
Rhinoskopi posterior
Laboratory : Routine blood test (hemoglobin, hematocrite, leukocyte, trombocyte, estimated
sedimentation rate)
g. Treatment :
Systemic Antibiotik (Amoksisilin 40 mg/ KgBB/ day : 3 dosis), 3 day
Parasetamol 500 mg, tab PO, if febris
Miringotomi
h. Prognosis :
q.a vitam

: bonam

q.a functionam
q.a sanationam :??

:??