NIGHT SHIFT REPORT

Friday, October 7th 2016

Consultant on duty : Dr., dr. Lina Lasminingrum,M.Kes,Sp.THT-KL

Chief on duty : dr. Wahyudi
Doctors on duty : dr. Dina
dr. Fani
dr. Sari
dr. Riri
 1. Girl, 3 years old
Chief Complain : beads in right nostril

Since 1 hours before admission, when she was playing, she put a

beads in her right nostril and can not be taken out. Nasal obstruction (+),

bleeding from nose (-), difficulty in breathing (-), cough (-), vomiting (-).

Because of her complain the family brought her to Hasan Sadikin

Hospital.
 PHYSICAL EXAMINATION
Generally State : Fully Alert , HR : 108x/m, RR : 35x/m, T : 36,20C
SpO2 99-100% Stridor : (-), retraction (-)

ORL-HNS examination :
- Both ear : external auditory canal not hyperemic +/+,
discharge -/-, cerumen -/-, ear drum intact +/+,
light reflex +/+, retroauricular not hyperemic +/+
- Right nasal cavity : mucosa not hyperemic (+), discharge (-), foreign body
beads (+) at 1/3 anterior nasal cavity, inferior turbinate eutrophy (+), air
passage decreased, septum deviation (-)
- Left nasal cavity : mucosa not hyperemic, discharge (-), inferior turbinate
eutrophy (+), air passage (+), septum deviation (-)
- OP : Tonsil : T1 T1 not hyperemic, pharynx : not hyperemic
- MF : symmetrical, no cranial nerve paralysis
- Neck: no lymph node enlargement
WD/ : Foreign body (beads) at
right nostril

Management :
plan extraction of foreign body
(beads) on right nostril /LA

Had been performed extraction of

foreign body (bead) on right
nostril foreign body beads (+),
bleeding (-), laceration (-)
 MANAGEMENT
WD/ : post extraction foreign body (beads) at
right nostril
Therapy :
Amoxycilin syrup 3x1 cth po
Parasetamol Syr 3x1 cth po
 2. Male, 59 y.o.
CC : difficulty in swallowing
Since 2 weeks prior to admission, the patient complained
difficulty in swallowing but still able to drink liquid diet. The
patient also complained difficulty in breathing since 1 month.
The patient also complain lump at the left neck since 6 months
ago. Pain in swallowing (-), drooling (-), tongue elevated (-),
history bleeding from the nose (+), nasal obstruction (-), double
vision (-), ear fullness (-), fever (-), history of DM (-), history of
hypertension (+). Patient has been done biopsy and was
diagnosed non keratinizing squamous cell carcinoma at regio
naspharyng. Patient was planned to do chemotherapy in internal
department. The patient was wished to be inserted orogastric
tube and refused to do tracheostomy from the beginning of the
diagnosed.
 Physical Examination:
General States : composmentis, dyspneu
BP : 160/100 mmHg Pulse : 108 x/m
RR : 24 x/m T : 38,30C
02 sat : 97% without O2
than
Stridor (+) inspiratoar , Retractions: Supra sternal (+),
epigastric(-), intercostals (-)
ENT state :
Both ears: ear canals not hyperemic +/+,
discharge -/- , ear drums +/+, light cone reflex +/+,
RA not hyperemic +/+
Nasal cavity: mucous not hyperemic +/+, inferior
turbinate eutrophy +/+, septum deviation (-), air
passage +/+
NPOP : palatum bulging(+), left posterior pharyng
is bulging, tonsillar T1-T1 not hyperemic
MF : symmetric, no cranial nerve paralysis
Neck : a/r Colli Sinistra level II-III mass, 4x3x2 cm,
hard, fixated
 LABORATORY FINDINGS :

Hb : 12,2 gr/dl Ur : 27 mg/dL

Ht : 35 Cr : 0,80 mg/dL
L : 19.300/mm3 SGOT : 23
Trom: 479.000/mm3 SGPT : 16
PT : 11,2 Blood Glucose : 111 mg/dL
aPTT : 27,9 Na : 139mEq
K : 5,0 mEq
Ca : 4,97
Mg : 2,21
Clinical Pictures
Neck Soft Tissue X-ray
Chest X-ray :
Diagnosis
disphagia due to palatum bulging ec nasopharyngeal
carcinoma T3N0M0 stage 3 + grade 1 upper airway
obstruction due to Carcinoma Nasopharyng T3 N0
M0
Management:
IVFD RL 20 gtt/mnt
O2 3 L/mnt
Plan to Tracheostomy/LA patient and family
refused
Plan for orogastric tube insertion had been done
Consult to Internal Department
Answer from Internal Department
WD/ Carcinoma Nasopharyng stage IV +
paraneoplastic syndrome + grade 1 upper
airway obstruction
Management :
- O2 3 L/mnt
- Plan to do chemotherapy as scheduled
- Others submitted to ORL-HNS
 Diagnosis
disphagia due to palatum bulging ec nasopharyngeal
carcinoma T3N0M0 stage 3 + grade 1 upper airway
obstruction due to Carcinoma Nasopharyng T3 N0 M0 +
Paraneoplastik Syndrome

Management :
O2 3 L/mnt
Plan to Tracheostomy/LA
Plan to biopsy Nasopharyng/LA
Liquid diet 6x250cc/day
 3. Female, 14 years old
Patient was referred from Sekarwangi Sukabumi Hospital
with wd/chronic mastoiditis
CC : headache
The patient was complaining a headache since 2 days ago,
with some purulent secret frome her left ear since 7 days
ago that relaps every month for along 3 years. The
complained was accompanied with fever since 1 week
ago. Less than a day ago, she was unconscious. She had
been hospitalized since 2 days ago because of her
complain that the headache getting worse,
she was referred to Hasan Sadikin Hospital
 Physical Examination:
General States : composmentis, dyspneu
BP : 110/70 mmHg Pulse : 108 x/m
RR : 24 x/m T : 38,30C
02 sat : 99% without O2
than
Stridor (-) , Retractions: Supra sternal (-),epigastric(-),
intercostals (-)
ENT state :
Right ears: ear canals not hyperemic, discharge (-),
Ear drum intact, light cone(+), RA not hyperemic +
Left ears: ear canals not hyperemic, discharge (+)
mucopurullent, ear wax (-), ear drums total perforated,
light cone (-), RA not hyperemic
Nasal cavity: mucous not hyperemic (+/+), inferior
turbinate eutrophy (+/+), septum deviation (-), air
passage (+/+)
NPOP : Tonsil T1-T1 not hyperemic, pharynx not
hyperemic
MF : symmetric, no cranial nerve paralysis
Neck : no neck node enlargement.
 LABORATORY FINDINGS :

Hb : 12,3 gr/dl Ur : 28 mg/dL

Ht : 38 Cr : 0,46 mg/dL
L : 17.400/mm3 SGOT : 27
Trom: 481.000/mm3 SGPT : 42
PT : 10,3 Blood Glucose : 108 mg/dL
aPTT : 20,8 Na : 139 mEq
K : 3,5 mEq
Clinical Pictures
Schuller X-ray
Chest X-ray :
Diagnosis
Left ear chronic supurative otitis media susp maligna with
intracranial complication + left ear chronic mastoiditis
Management:
Observation vital sign
IVFD RL 20 gtt/mnt
Check culture and resistance left ear secrete
Temporal CT scan axial coronal view, 1-3 mm slice, with and without
contrast
Ceftriaxon 2x1 gr iv
Ketorolac 2x30 mg iv
Tarivid otic 2x4 gtt left ear
Consult to Neuro surgery Department
Answer from Neuro Surgery Department
WD/ susp Increase intracranial pressure
Management :
- Conservative
- No particular action from neuro surgery
department at this time
- Suggestion : CT scan
 4. Male, 28 years old
CC : Difficulty in swallowing

Since 3 days prior to admission, the patient was complained

difficulty in swallowing and opening his mouth. Patient still
able to eat liquid diet and drink. Pain on swallowing (+), hot
potatoes voice (+), drooling (-), fever (+), hoarseness (-),
History of dental carries (+), history of cough with purulent
discharge (-), difficulty on breathing (-), trauma (-), History of
hipertension (-), DM (-). Because of his complain, he was
brougth to Hasan Sadikin Hospital.
 PHYSICAL EXAMINATION
General State : compos mentis
BP : 120/80 mmhg HR : 90x/m regular
RR : 22x/m Temp : 38,0 C
Saturation : 98%

Stridor (-) retraction suprasternal (-), retraction intercostal (-),

retraction epigastrium (-).
ENT Examination :
Ears : mucosa not hyperemic +/+ discharge -/-, cerument -/-,
ear drum intact +/+, cone of reflex +/+, retroauricular not
hyperemic +/+
Nasal cavity : mucosa not hyperemic +/+, discharge -/- , inferior
turbinate eutrophy +/+, SD (-), air passage +/+.
Oral cavity : To = T1-T3, hyperemic (+)/(-), palatum bulging (+),
uvula shift to the right, pharynx difficult to be
evaluated
Maxillofacial : simetric, no cranial nerve paralysis
Neck : Neck node enlargement (-)
Clinical picture
Neck Soft Tissue X-ray
Chest X-ray :
 WD/ Left Peritonsilar Abscess

Management :
- Observation of vital sign
- IVFD RL 20 drops/mnt
- Ceftriaxon 1x2 gr iv
- Ketorolac 2x30 mg iv
- Ranitidin 2x50 mg iv
- Consult to Oral Surgery Department
- Plan to perform tapping/LA patient refuse
- If tapping (+) Plan to perform drainage incision
abscess in LA patient refuse
 Answer from Oral Surgery departement

WD/ Left Peritonsilar Abscess + Chronic apical

periodontitis due to pulp ganggren 3.8
Management:
- Oral Hygiene Instruction
- Panoramic X ray
- Plan to perform tooth ekstraction 3.8
- Others submit to ENT departement
WD/ Left Peritonsilar Abscess + Chronic apical
periodontitis due to pulp ganggren 3.8
Management :
- Observation of vital sign
- IVFD RL 20 drops/mnt
- Ceftriaxon 1x2 gr iv
- Ketorolac 2x30 mg iv
- Ranitidin 2x50 mg iv
- Oral Hygiene Instruction
- Panoramic X ray
- Plan to perform tooth ekstraction 3.8
- Plan to perform tapping/LA , If tapping (+) Plan to
perform drainage incision abscess patient refuse
- Patient was force discharge
 5. Baby girl, 6 month
The patient was consulted from Pediatric Department with WD/
laryngomalacia + bronchopneumonia + spastic quadriplegia type
cerebral palsy + DD/ -VSD
- CALSD
Chief Complain : Snoring
Since age 1 month patient was oftenly snoring. Snore
disappear with position. Chocking when feeding (-) Difficulty in
breathing since 2 weeks prior to admission, fever (+), cough (-)
 PHYSICAL EXAMINATION
Generally State : Fully Alert , HR : 138x/m, RR : 48x/m, T : 36,50C, O2
saturation 95% with O2 1 lpm via nasal cannule
Stridor (+) inspiratoar, retraction (+) at suprasternal and epigastrium

ORL-HNS examination :
-Both ear : external auditory canal not hyperemic +/+, discharge -/-,
cerumen -/-, ear drum intact +/+, light reflex +/+,
retroauricular not hyperemic +/+
- Right nasal cavity : NGT inserted, others difficult to evaluate
- Left nasal cavity : mucosa not hyperemic +/+, discharge -/-, inferior
turbinate eutrophy +/+, septal deviation (-),
air passage +/+
- OP : pharynx not hyperemic, tonsil : T1 T1 not hyperemic,
- MF : symmetrical, no nerve cranial paralysis
- Neck : no neck node enlargement
CHEST X-RAY
 MANAGEMENT
WD/ susp. laryngomalacia + bronchopneumonia + spastic
quadriplegia type cerebral palsy + DD/ -VSD
- CALSD

Management:
Observation vital sign
O2 via nasal cannule 1 liters/minute
Plan to perform RLFO/LA in ORL-HNS outward Clinic
Others submitted to Pediatric Department
THANK YOU