Scenario B Block 19 Mr.

M 67 years old, came to the ER RSUD X was escorted by his son with symptoms of nose bleeds that flows from both nostrils after an hour ago and did not stop. Blood comes out flowing fairly fast and the patient already using two hand towels to wipe it. He also complained that many of the blood that has been swallowed. One day before, the patient also experience similar nose bleeds, but after half an hour the blood stops. The patient have a history of high blood pressure since five years ago but never examined regularly. Physical Examination: VS: BP 140/90 mmHg, N = 90x/min, T = 36,8 C, RR= 28x/min Head: Pupil Isocor, conjunctiva rather pale Neck: JVP not elevated Thorax: C/P dbn Abd: dbn Exremity: dbn Local status ENT Ears :

: External meatus akustikus: t.a.a Tympanis membrane: t.a.a

Nose

: Anterior rhinoscopy: blood (+) flows profuse, blood clot (+), mucosal hyperemi, concha inferior: eutrophy Posterior rhinoscopy: difficult to assess

Orofaring

: Blood flow (+) of lateral orofaring wall

Lab: Hb 14g% , leuko 10.000, thrombo 200.000, Hmt 27, Ct 2, vt 4, lab stated dbn Photo X-ray: C/P dbn.

Term Clarification 1. Nose bleed 2. Nostrils 3. Two hand towels 4. Swallowed blood 5. High blood pressure 6. Pupil isocor 7. Conjunctiva rather pale 8. JVP 9. External meatus akustikus 10. Tymphanic membrane 11. Rhinoscopy 12. Lateral orofaring wall

Problem Identification
1. Mr. M. 67 y.o with complaint of nose bleeds that flows from both nostril after 1 hour

ago and did not stop. 2. History: Blood comes out flowing fairly fast and patient already using two hand towels to wipe it. Many of blood has been swallowed One day before: he also experience similar nose bleeds, but after half an hour the blood stops. History of hypertension since 5 years ago but never examined regularly.

3. Physical Examination: -

BP 140/90 mmHg, RR 28x/min Head: conjunctiva rather pale Nose: anterior rhinoscopy: Blood (+) flows profuse, blood clot (+), mucosal hyperemi, concha inferior: eutrophy. Posterior rhinoscopy: difficult to assess.

Orofaring : Blood flow (+) of lateral orofaring wall

Problem Analysis 1. a. Whats anatomy and physiology of ENT? b. Whats cause and mechanism of noose bleed? c. What are types of nose bleed? d. Why the blood flows from both nostrils? e. Why the blood cant stop after one hour? f. Is there any correlation between the epistaxis and the age? 2. a. How many approximately the bloods comes out by using two handstowels? b. What are the effect of blood comes out flowing fairly fast? c. Why the bood can be swallowed? d. What is the effect of swallowed blood? e. Why the epistaxis one day before can stop after half an hours, but now cant stop? f. What is the correlation between epistaxis one day before and epistaxis now? g. What is the correlation between hypertension and epistaxis? 3. a. What is the interpretation of Physical examination, ENT, and Lab result? b. What is the correlation between Physical examination, ENT, and Lab result with his nose bleed? c. How is the mechanism of the PE, ENT, and lab result? 4. a. What is the differential diagnose for this case? b. How to diagnose? c. What is the working diagnose for this case? d. How is the management? e. What is the prognosis? f. What is the complication?

Hypothesis Mr. M 67 years old, suffered from Epistaxis posterior due to Hypertension grade 2.

Synthesis