bst dr. soetedjo
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7/23/2019 BST Dr. Soetedjo
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Nama Lengkap : Tn. DK Jenis Kelamin :Laki-laki
Usia : 63 tahun Ruangan : -
Pekerjaan : Pensiunan DPJP : dr. ndra !apta"
!p.T#T
$gama : Kristen
!tatus Pernikahan : %enikah
Tanggal Dira&at : -
$lamat
Jl. Ke'api N(.) RT ) R& * Kel. Turangga"
Ke'. Lengk(ng-+andung
Tanggal Diperiksa : 3, Juni *,)
DNTT$! P$!N
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$N$%N!!• Keluhan utama ! sering keluar ingus
• "namnesis khusus !
Se#rang laki-laki usia $% tahun datang dengan
keluhan sering keluar ingus dari hidung se&elahkiri se'ak ( 2 &ulan )ang lalu* Keluhan dirasakanterus-menerus+ dan tidak di,engaruhi uaadingin* Ingus )ang keluar kental+ &er.arna kuningkehi'auan dan &er&au+ darah /-* Keluhan 'uga
disertai n)eri ,ada daerah ,i,i+ se,erti tertekan*Hidung sering dirasakan tersum&at* asien 'ugamengeluh terasa adan)a lendir di tengg#r#kan*
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$N$%N!!• Ri.a)at en)akit ahulu! asien sering
mengalami hidung tersum&at dan &ersin-&ersin se'ak keil* Hi,ertensi /-+ M /-
• Ri.a)at en)akit Keluarga! Tidak ada)ang menderita sakit se,erti ini dalamkeluarga
• Usaha &er#&at! Sudah minum Mi3agri,ta&let teta,i tidak ada ,eru&ahan
• Ri.a)at "lergi! -
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Status Generalis
Keadaan Umum : Baik
Kesadaran : Compos Mentis
Kesan sakit : sedang
Nadi : 80 x/ menit
Pernapasan : 20x/ menit
ekanan dara! : "20/80 mm#g
Su!u : $%&8 0 CB : "%8 'm
BB : (0 kg
BM) : 2* kg/m2
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P+M+,)KS--N .)S)K
• t#sk#,i! M"6 n#rmal+ 7"6 muk#sa tidak hi,eremis+ serumen /8+mem&ran tim,ani intak+ um&# /8+ re9eks aha)a /8
• Rin#sk#,i "nteri#r ! ares anteri#r ter&uka+ deviasi se,tum+ avum nasihi,eremis+ hi,ertr#: #nha /8+ sekret muk#,urulen /8
• Rin#sk#,i #steri#r ! 7h#anae ter&uka+ sekret muk#,urulen /8+ muaratu&a ter&uka+ t#rus tu&arius n#rmal+ aden#id tidak mem&esar+ ;#ssaR#senmuler n#rmal
• <aring#sk#,i ! /8+ ,ilar anteri#r ,#steri#r n#rmal+ T#nsila ,alatina
T1=T1+ kr),ta /-+ granul /-+ dinding ,#steri#r ;aring hi,eremis+ granul /8/r#;aring
• <aring#sk#,i ! Lidah+ gigi+ ,alatum durum+ ,alatum m#le+ uvula sentraln#rmal*
/ral 7avit)
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P+M+,)KS--N .)S)K
• Laring#sk#,i Indirek! aditus laringister&uka+ e,igl#ttis n#rmal*
• Kelen'ar leher ! tidak ada,em&esaran kelen'ar di leher
• endengaran ! tidak ada gangguan,endengaran
• >esti&uler ! tidak ada gangguankeseim&angan
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Pemeriksaan Penunang
• <#t# ,#sisi ?ater@s
'**! S+,SM!-+!'+S"+'+ &E'+S+
/!+'!
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Diagn(sa utama : Rhin(sinusitis %a/illaris kiri
D+!*S+S "E'!
•Ka nex $x 20 mg
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PE!&!!"S!!! %edikament(sa
$nti0i(tik : %etr(nida1(l 2/,, mg selama ), hari
Dek(ngestan t(pikal : Pseud(eedrin nasal spra4
%uk(litik : $m0r(/(l 3/6, mg
Ka nex $x 20 mg• Norages $ x 20 mg•PC s4r $x2 't!•5ani3ed $x" 't!•onperidone $x" 't!•-nta'id $x""/2 't!
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PE!&!!"S!!! N(n %edikament(sa
5!! 5un'ti(nal nd(s'(p4 !inus !urger47
•Ka nex $x 20 mg
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P'*S+S
8u( ad 9itam : $d 0(nam
8u( ad un'ti(nam : $d 0(nam
8u( ad sanati(nam : $d 0(nam
Ka nex $x 20 mg• Norages $ x 20 mg•PC s4r $x2 't!•5ani3ed $x" 't!•onperidone $x" 't!•-nta'id $x""/2 't!
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Anatomic location of the
sinus ostia
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e:nisi
Rhin#sinusitis adalah in9amasi ,adahidung dan sinus ,aranasal )ang disertaidengan 2 ge'ala = le&ih &eru,a!
• Hidung tersum&at• Rin#re anteri#r = ,#steri#r
• )eri ,ada .a'ah = rasa ,enuh di .a'ah
• Hi,#smia = an#smia• Salah satu dari ge'ala terse&ut harus
&eru,a hidung tersum&at = rin#re
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Klasi:kasi
• ?aktu!
– "kut /sam,ai dengan A minggu dange'ala hilang
– Su&akut /5 sam,ai 12 minggu – Kr#nik /C 12 minggu tan,a ,er&aikan
ge'ala
• Ke,arahan />"S 0-10 m!
– Mild
– M#derate
– Severe
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6ti#l#gi /#rganisme Dinsidensi /E
• "er#&i &ateria
oStre,* ,neum#niae /%0
o"l,ha D &eta hem#l)ti Stre, /5
o
Sta,h* aureus /5oBranhamella atarrhalis /15 t# 20
oHem#,hilus in9uenFae /25 t# %0
o6sherihia #li /5
•
"ner#&es /10 E aute+ $$ E hr#ni• <ungi /2 t# 5
• >iruses /5 t# 10
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Ma'#r Min#r
<aial,ain=,ressure=;ulln
essasal
#&struti#n=&l#ka
geasal #r ,#stnasaldisharge=,urulen
e/&) hist#r) #r
,h)sial
Headahes<ever
/#ther than auterhin#sinusitis
Halit#sis
<atigueental ,ain7#ugh6ar
,ain=,ressure=;ullness
Signs an Sm2toms!sso3iate it te
Diagnosis of
'inosinsitis
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ain atterns .ith "uteSinusitis
• Ma3illar) sinusitis•Unilateral ,ain #ver heek&#ne
•Ma3illar) t##thahe
•eri#r&ital ,ain
• Tem,#ral headahe
•ain .#rse i; head u,right
•
ain &etter i; head su,ine
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• 6thm#id sinusitis
•
Medial anthal ,ain•Medial ,eri#r&ital #r tem,#ral headahe
•ain .#rsened &) >alsalva #r i; su,ine
• S,hen#iditis
•Retr##r&ital+ tem,#ral+ #r vertialheadahe
•ain .#rse su,ine #r &ending ;#r.ard
• <r#ntal
•<r#ntal headahe
•ain .#rse su,ine
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Use #; aranasal Sinus Transilluminati#n t# iagn#se
Sinusitis• <irst rem#ve ,atientGs dentures
• Use darkened r##m
•
Shield light s#ure ;r#m #&serverGs e)es• Use ?elh "ll)n transilluminat#r #r Mini-
Mag Lite
• Shine light #ver ma3* sinus D #&serve
light transmissi#n thru hard ,alate• Re,#rt results as #,aue+ dull+ #r n#rmal
;#r either side
• #t use;ul ;#r ;r#ntal sinuses sine the)
#;ten have devel#,ed as)mmetriall)
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"ute SinusitisRadi#gra,h)
• lain :lms n#t as sensitive as 7T
• Radi#gra,hi signs #; sinus
,ath#l#g) !• "ir 9uid levels
• artial #r #m,lete #,ai:ati#n
•
B#n) .all dis,laement• A mm #r m#re #; mu#sal .all
thikening
• Single ?aterGs vie. has high
#n#rdane .ith A vie. sinus series
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Water’s view showing air-
fluid level in right maxillary
sinus and mucosalthickening in left maxillary
sinus
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Lateral view of normal frontal and sphenoid sinuses
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Opacification of the frontal sinuses