Case report

PATIENT IDENTITY
Name : KJ
Medical Record : 40.01.08
Age : 8 years old
Sex : male
Job : student
Address
: JR. Pintu Padang Madat,
Tunggul-Pasaman Timur

Anamnesis
ANAMNESIS
A male, 8 years old, came to ENT HNS Department
of Dr. M. Djamil Hospital on February, 16 th , 2015 with:
Chief Complaint :
Pain when swallow since 1 week ago
Clinical Course :
Pain when swallow since 1 week ago. Pain was felt
when swallow saliva or when eating food.
Initially, Pain swallowing felt since 9 months ago,
intermitten. It was felt especially when patient has a
fever, cough and cold

Anamnesis
The patient's family said, since 9 months ago,
patients snore while sleeping and some times
awakened from sleep due to shortness of breath.
The patient's family said that the patient's mouth,
smell bad since 9 months ago.
There are fever since 9 months ago, approximately 8
times in 9 months accompanied by cough and colds.
There was pain in the left ear accompanied by
ringing in the ears, especially when the patient has a
fever. Hearing loss does not exist.
Hoarseness since 3 months ago.
Patients like drinking ice and eat snacks at school
almost every day.

 There are no sneezing in the morning nor

history of drug allergy and food.
There are no breathless
The patient had been treated in public
health centers and diagnosed with
enlargement of tonsils and received the
drug from the family doctor but forgot the
name of the medicine.

Anamnesis
Past Medical History
The patient has been suffering from complaints like
this since 9 months ago
The patient had no history of asthma, nor allergies
to food or drugs and never sneezing in the morning
more than 5 times.
The patient had been treated previously for
diseases like this.
History of Familial Disease
There is no family members that have same
symptoms or disease same with patient.
There is no atophy in family.
History of Work, Social, Economy and Habit
Patient is an elementary school student

Physical examination
Generalis State
General appearance : good
Awareness : CMC
Blood Pressure : 110/ 70
Heart Rate : 90x/minutes
Respiratory Rate : 20 x/minutes
Temperature` : 37 oC
Head : Normocephal
Eyes : Conjunctiva : anemic (-) , Sclera : icteric (-)
Pulmo : Within normal limits
Cor : Within normal limits
Abdomen : Within normal limits
Extremitas : Within normal limits

EAR, NOSE, AND THROAT

EXAMINATION

Examination
Auricular

Wall and canal of ear

Secrete/cerumen

Abnormality
Congenital abnormality

Dekstra
-

Sinistra
-

Trauma
Inflammation
Metabolic disorder

Retraction pain
Tragus pain
Wide enough (N)
Narrow
Hyperemic
Oedema
Mass
Stink
Colour
Amount
Type

Wide enough (N)

Wide enough(N)

yellowish
A few
dry

yellowish
A few
dry

White
+
-

white
+
-

+
normal

+
Normal

Tymphany membrane
Intact

Color
Reflect of light
Bulging
Retraction
Atrophy
Amount of perforation

Perforation
Type
Quadran
Margin
Picture
Mastoid

Tuning fork test

Audiometry

Inflammation sign
Fistula
Cicatrix
Tenderness
Rinne
Schwabach
Weber
Conclusion

theres no lateralisation
Normal
Not examined

NOSE, PARANASAL SINUS

Examination
Outer nose

Abnormality
Deformity
Congenital
abnormalities
Trauma
Inflammation
Mass

Dextra
-

Sinistra
-

Paranasal Synus
Examination

Dextra

Sinistra

Tenderness

Examination
Vestibulum
Cavum nasal
Secrete

Inferior Concha

Middle Concha

Septal

Mass

Abnormality
Vibrise
Inflammation
Wide enough (N)
Location
Type
Amount
Smell
Size
Colour
Surface
Oedema
Size
Colour
Surface
Oedema
Deviation
Surface
Colour
Spina
Crista
Abscess
Perforation
Location
Form
Size
Surface
Colour
Consistency
Easily swayed
Vasoconstrictor

Dextra
+
-

Sinistra
+
-

+
serous
A few
eutrophy
Pink
smooth
eutrophy
pink
smooth
Smooth
Pink
-

+
serous
A few
Eutrophy
Pink
Smooth
eutrophy
pink
smooth
Smooth
Pink
-

RHINOSCOPY POSTERIOR
Examination

Abnormality

Dextra

Sinistra

Choana

Wide enough (N)

Narrow
Wide

difficult to assess

difficult to assess

difficult to assess

difficult to assess

Oedema
Granulation tissue
Size

difficult to assess
difficult to assess

difficult to assess
difficult to assess

difficult to assess

difficult to assess

Colour
Surface
Oedema

difficult to assess
difficult to assess
difficult to assess

difficult to assess
difficult to assess
difficult to assess

difficult to assess

difficult to assess

difficult to assess

difficult to assess

Mucosa oedema
Location

difficult to assess

difficult to assess

difficult to assess

difficult to assess

Size

difficult to assess

difficult to assess

Form
Surface

difficult to assess
difficult to assess

difficult to assess
difficult to assess

difficult to assess

difficult to assess

difficult to assess

difficult to assess

Colour
Mucosa

Inferior concha

Adenoid
Eustachian tube orificium

Secrete

Mass

Post Nasal Drip

Type

OROPHARYNX AND MOUTH

Examination
Pharyngeal arch
Palatum mole

Pharyngeal wall
Tonsil

Peritonsil
Tumor

Teeth
Tongue

Picture

Abnormality
Simetris
Colour
Oedema
Spot/exudates
Colour
Surface
Size
Colour
Surface
Crypt
Detritus
Exudate
Adhesion with pillar
Colour
Oedema
Abscess
Location
Form
Size
Surface
Consistency
Caries/Radix
Conclusion
Colour
Form
Deviation
Mass

Dextra

Sinistra
Simetris
Pink
Pink
Not Flat

T3
hiperemic
Not Smooth
enlargement
-

T4
hipremic
Not Smooth
enlargement
+
-

hiperemic
-

hiperemic
+
Lack of oral hygiene
Pink
Normal
-

LARYNGOSCOPY INDIRECT
Examination
Epiglotis

Ariteniod

Ventrikular band
Plica vocalis

Subglotis/trachea
Sinus piriformis
Vallecula
Picture

Abnormality
Form
Colour
Oedema
Margin
Mass
Colour
Oedema
Mass
Movement
Colour
Oedema
Mass
Colour
Movement
Medial margin
Mass
Mass
Secrete
Mass
Secrete
Mass
Secrete (type)

Dextra

Sinistra

difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess
difficult to assess

Cervical Examination
there are enlargement of lymph
nodes below the left mandible,as
much as 1 piece of round shape, size
1x1x1 cm, chewy consistency,
mobile

Diagnosis
Working diagnosis : Chronic Tonsillitis
Secondary diagnosis : Caries of
Dentis

Prompts Examination:
- Routine laboratory: hemoglobin,
hematocrit, leukocytes, LED
- Culture and resistance tests of
bacterium of the tonsils.

Therapy
Ceftriaxone 1x500 mg IV
Metylprednisolone 3x4mg
Planning : Tonsilectomy

Laboratory examination (February,

17th.2015)

Hb
: 12,8 g/dl
Leucocytes : 20370/mm3
: 34%
Ht
Trombosite : 513000/mm3
Pt
: 9,4 second
Aptt : 29,6 second

Discussion

Chronic Tonsillitis