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ALLERGIC RHINITIS
Supervisor
dr. H. Oscar Djauhari, Sp. THT-KL
Presentant
Rizgah M Jawas 2012.730.091
Army Oktavianto 2012.730.011
Yuka Puspita A. 2012.730.110
Clinical Rotation
Otolaryngology, Head and Neck Department
Medical Faculty of Muhammadiyah Jakarta University Syamsudin, S.H.
Regional General Hospital, Sukabumi
Period of 13th June 17th July 2016
PATIENTS IDENTITY
Name
Age
Gender
Race
Address
Weight
Height
: NK
: 9 years old
: Male
: Sundanese
: KP. Cihereus, Cibadak
: 35 kg
: 140 cm
ANAMNESIS
Chief complaint : unconsciosness
Sneezing
Itchy nose
Mucus liquid
Nasal Obstruction
History of present illness :
Son, 9 years old, came to the hospital with complaints continuous colds
within one weeks ago on his nose. The patient also complaints about Itchy
nose, sneezing, mucus liquid, and nasal obstruction since 3 days ago.
Ear
: moderately ill
: Compos mentis
: 88 times per minute
: 16 times per minute
: 36,5 oC
Right ear
Auricle
(-)
Canalis Acousticus Externa
Tymphanic membrane
Whisper test
Left ear
Auricle
(-)
Tymphanic membrane
Whisper test
: Normal.
Nose
Inspection nose
Right Nose
Mucous membrane
Concha
: eutrophy
Cavum
Septum
Left nose
: normal
Mucous membrane
Concha
: eutrophy
Cavum
Septum
: normal
Mucous membrane
Arcus anterior
Pharynx
Tonsil
NPOP
Neck
: lymphadenopathy -/-
Therapy
Patient education
Avoiding allergens and irritants
Pharmacotherapy
antihistamines
decongestants
intranasal corticosteroids
Immunotherapy