Skenario B Blok 14 2018

A 15 years old boy was taken by his mother to clinic at local general hospital. The main
complain was sorethroat since 2 days ago. There was fever, but no cough, rhinorhea and pain
in both ears. The main complain had been recurred since 2 years ago and the last main
complain recurred 3 month ago

Physical examination:
Vital sign
Blood pressure : 120/80mmHg
Pulse : 80 X/min
Respiratory rate : 24x/min
Core temperature : 38.5oC

ENT Examination
Right Ear Left Ear
Otoscopy Ear canal: within normal Ear canal: within normal
Ear drum: within normal Ear drum: within normal

Right Nose Left Nose

Anterior Rhinoscopy Nasal mucosa: within normal Nasal mucosa: within normal
Inferior turbinate: eutrofi Inferior turbinate: eutrofi
Nasal septum no deviation
Nasal secret (-) Nasal secret (-)
Oropharynx Tonsil: T3-T3, Hyperemis (+), Detritus (+), Widened Crypt
(+)
Posterior Wall: Hyperemis (+), Granules (+), post-nasal drip
(+)

Laboratory Examination
Hb 12.5gr%, WBC: 13.000 mm3, Trombosit: 250.000 mm3

I. Klasifikasi Istilah
Sorethroat A sorethroat is pain, scratchiness or
irritation of the throat that often worsnens
when you swallow. (mayo-clinic)
Pain in the throat due to inflammation of
the fauces and pharynx. (merriam-
webster)
Rhinorhea Sekresi mukus encer dari hidung.
(dorland)
An excessive discharge of mucus from the
nose. (medical dictionary)
otoscopy Procedure by which the external auditory
canal and ear drum of a patient is
examined. (ortholaryngology)
Alat untuk melakukan inspeksi dan
 auskultasi. (dorland)
Is an examination that involves looking
into the ear with an instrument called an
otoscope (or auriscope). (netdoctor.co.uk)
Anterior rhinoscopy Pemeriksaan hidung dengan
menggunakan spekulum melalui naras
anterior. (dorland)
Is an examination of the nasal cavities
enabling to note nasal secretions, swelling
of the turbinates, properties of the
mucosal surface, position of nasal septum,
ulcerations of presence of forein bodie.
Inferior turbinate: eutrofi Two spongy curled bones that protrude
into the nasal passages. (sinus surgery
prosedur)
Oropharynx The part of the throat at the back of the
mouth behind the oral cavity. (NCBI)
Bagian faring yang terletak di antara
palatum molle sampai tepi atas dari
epiglotis. (dorland)
Tonsil: T3-T3 Tonsillar enlargement up to the level of
the uvula. (tonsilcure)
Detritus Bahan partikular yang dihasilkan atau
tersisa setelah disintegrasi substansi atau
jaringan. (dorland)
Produk hasil dari disintegrasi atau
destruksi. (meriam-webster)
Widened crypt Is the widening of a small slit-like
invagination on surface of the palatine or
pharyngeal tonsil. (medical dictionary)
The crypt is drawn somewhat widened to
permit the lymphatic nodules bulging into
the crypt to be seen. (human microscopic
anatomy)
Granules oropharynx Butiran kecil yang berada di oropharynx.
(dorland)
Small particle at the back of the mouth
behind the oral cavity due to
inflammation. (NCBI)
Small particle at the back of the mouth
made up of masses of lymphoid cell group
around the mouth of the duct of the
mucous gland (annals of otology,
rhinology and laryngology)
Post-nasal drip Is the medical term that describes when
mucus from your nose or sinuses drips
down the back of your throat.
(Healthdirect.gov.au)
Flow of mucus secretion from the
posterior part of the nasal cavity onto the
 wall of the pharynx occurring usually as a
chronic accompaniment of an allergic
state. (meriam-webster)

II. Identifikasi masalah

1. A 15 years old boy has a main complain of sorethroat since 2 days ago. (keluhan
utama)
2. There was fever, but no cough, rhinorhea and pain in both ears. (keluhan
tambahan)
3. The main complain had been recur since 2 years ago and the last main complain
recur 3 month ago. (riwayat perjalanan penyakit)
4. Physical examination:
Vital sign
Blood pressure : 120/80mmHg
Pulse : 80 X/min
Respiratory rate : 24x/min
Core temperature : 38.5oC

5. ENT Examination
Right Ear Left Ear
Otoscopy Ear canal: within normal Ear canal: within normal
Ear drum: within normal Ear drum: within normal

Right Nose Left Nose

Anterior Rhinoscopy Nasal mucosa: within Nasal mucosa: within
normal normal
Inferior turbinate: eutrofi Inferior turbinate: eutrofi
Nasal septum no deviation
Nasal secret (-) Nasal secret (-)
Oropharynx Tonsil: T3-T3, Hyperemis (+), Detritus (+), Widened
Crypt (+)
Posterior Wall: Hyperemis (+), Granules (+), post-nasal
drip (+)

6. Laboratory Examination
Hb 12.5gr%, WBC: 13.000 mm3, Trombosit: 250.000 mm3

III. Analisis masalah

1. A 15 years old boy has a main complain of sorethroat since 2 days ago.
a. Apa hubungan umur dan jenis kelamin dengan kasus ini?
b. Bagaimana mekanisme nyeri tenggorokan pada kasus ini?
c. Apa saja penyebab inflamasi pada tenggorokan?
d. Bagaimana tata laksana nyeri tenggorokan pada kasus ini?
 2. There was fever, but no cough, rhinorrhea and pain in both ears.
a. Bagaimana mekanisme demam pada kasus ini?
b. Apa hubungan keluhan demam dengan nyeri tenggorokan?
c. Apa makna dari tidak ada batuk, rhinorrhea, dan nyeri di kedua telinga?

3. The main complain had been recurred since 2 years ago and the last main
complain recur 3 month ago.
a. Mengapa keluhan utama terjadi berulang sejak 2 tahun dan 3 bulan yang
lalu?

4. Physical examination:
Vital sign
Blood pressure : 120/80mmHg
Pulse : 80 X/min
Respiratory rate : 24x/min
Core temperature : 38.5oC
a. Apa interpretasi dari hasil pemeriksaan tanda vital?
b. Bagaimana mekanisme terjadinya abnormalitas dari hasil pemeriksaan
tanda vital?
5. ENT Examination
Right Ear Left Ear
Otoscopy Ear canal: within normal Ear canal: within normal
Ear drum: within normal Ear drum: within normal

Right Nose Left Nose

Anterior Rhinoscopy Nasal mucosa: within Nasal mucosa: within
normal normal
Inferior turbinate: eutrofi Inferior turbinate: eutrofi
Nasal septum no deviation
Nasal secret (-) Nasal secret (-)
Oropharynx Tonsil: T3-T3, Hyperemis (+), Detritus (+), Widened
Crypt (+)
Posterior Wall: Hyperemis (+), Granules (+), post-nasal
drip (+)
a. Apa interpretasi dari hasil pemeriksaan THT?
b. Bagaimana mekanisme terjadinya abnormalitas dari hasil pemeriksaan THT?

6. Laboratory Examination
Hb 12.5gr%, WBC: 13.000 mm3, Trombosit: 250.000 mm3
a. Apa interpretasi dari hasil pemeriksaan laboratorium?
b. Bagaimana mekanisme terjadinya abnormalitas dari hasil pemeriksaan
laboratorium?

7. Kesimpulan apa yang dapat ditarik dari hasil anamnesis, pemeriksaan fisik,
pemeriksaan THT, dan pemeriksaan laboratorium?
 Hipotesis
Seorang anak berumur 15 tahun menderita tonsilopharyngitis eksaserbasi akut.

IV. Learning issues

1. Anatomi saluran pernafasan atas
2. Histologi saluran pernafasan atas
3. Fisiologi saluran pernafasan atas
4. Tonsilopharyngitis
5. Pemeriksaan THT