Patient Identity

Name :Y
Age : 5 Years old
Examination date : 18 th December 2019
 Chief Complaint

Shortness of breath when lying down (+), Pain (-)

 Vital Sign
General condition : Moderate Pain
Conciousness : Composmentis
Vital sign :

• BP : 110/70 mmhg
• HR: 100 x/minute
• RR: 24 x/minute
• T: 36,6 C
• SpO2: 98 %
 Ear Examination
Auris Externa DEXTRA SINISTRA
Auricle Normal Shape, mass (-), Normal Shape, mass (-),
tenderness (-) tenderness (-)

Pre auricle Tragal pain (-) Tragal Pain (-)

Edema (-) Edema (-)
Hyperemia (-) Hyperemia (-)
Fistulae (-) Fistulae (-)
Retro auricle Edema (-), hyperemia (-), Edema (-), hyperemia (-),
mass (-), fistulae (-), abscess mass (-), fistulae (-), abscess
(-), tenderness (-) (-), tenderness (-)
 EAC DEXTRA SINISTRA

Size and meatus wide Wide

Swelling (-) (-)
Furuncle (-) (-)
Content Of lumen
Discharge None None
Wax (-) (-)
Polyp (-) (-)
Foreign Body (-) (-)
 DEXTRA SINISTRA

Tympanic Membrane
Color Pearly Grey And Translucent Pearly Grey And Translucent

Bulging (-) (-)

Vesicle/ Bullae (-) (-)

Perforation (-) (-)

Light Reflex (+) (+)

Anterior Rhinoscopy
Without a nasal speculum

DEXTRA SINISTRA

Nasal vestibule Redness (-) swelling (-) Redness (-) swelling (-)

Nasal airway Obstruction (-) Obstruction (-)

With a nasal speculum
DEXTRA SINISTRA
Colour of the nasal Dull red (-), pale (-), Dull red (-), pale (-),
mucosa bluish (-) bluish (-)
Septum Deviated septum (-), perforations of the septum (-)

Turbinate eutrophic, Hyperemia (-) eutrophic, Hyperemia (-)

Oropharynx Examination
Inspection :
Palatine Tonsil : T3 – T3, Detritus (+), swelling (+), hyperemia
(+)
Uvula : In The Middle (+)
Pharyngeal Wall : Granule (-) Hyperemia (-) Ulcer (-)
Faucial Pillar : Hyperemia (-)
Neck Examination
Lymph Nodes : Enlargement (-)
Thyroid : Enlargement (-)
MAXILLOFACIAL
• Inspection : Symmetries, Local swelling (-),Malocclusion (-)
• Palpation : Pain (-), Crepitus (-)
Sinuses : Tenderness (-)
 Laboratory
3/12/2019

Hemoglobin 11,7 gr%

Hematokrit 34 %
Trombosit 264 mm^3
Leukosit 6,8 /mm^3
ASSESMENT
chronic Tonsilitis Hypertrophy + adenoid hypertrophy

Therapy Plan
1. IVFD RL 10 gtt/minute 1. Tonsilloadenoidectomy today
2. Anbacim 2 x 400 mg iv
3. Fasting 6 Hour Before Surgery