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Name : Mr. I
Age : 43 y.o
MR : 76 96 15 Gender : Male
Tribe : Minangkabau
Adress : Pesisir Selatan
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A male patient came to Dr. M. DjamilHospital on June 11th2014 with:
Main Complaint Patient was suggested by the radiotherapist
to do blood transfusion before continuingthe therapy.
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Patient has noticed as a nasopharyngeal carcinoma non
keratinizing stage IV B (T2N3aMO) durante 20th
Radiotherapy, thelaboratory finding has informed that Hb: 9,6 g/dl and he suggestedto do blood transfusion.
Patient has done the chemotherapy for twice.
Lump in the right side of neck since 5 month ago, and gettingsmaller after the radiotherapy.
The right ear feels blocked since 4 month ago.
There is history of nose blockage in the right cavity and it continuedto the left cavity about 4 month ago, and it lesser after theradiotherapy.
There is history of blood stained nose discharge about 4 month ago
and it doesnt happen anymore after the radiotherapy. There isnt difficulty to open mouth.
There isnt lump in armpits and groins.
Intermittent headache in the right side of head since 2 month ago.
There isnt history of blurred vision and double vision.
There isnt difficulty to swallow.
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Past Medical History
Lump in the right neck 2 years ago and he
had chemotherapy for 8 times in internalmedicine department. The lump appearedagain 4 months after the chemotherapy.
Family Medical History
There isnt any family member who hasmalignant disease.
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Social, Economic, and Habit History
The patient is a trader.
There isnt history of consuming salted fishroutinely.
History of consuming alcohol is present, forabout 10 ten years, about 1 glass per day.
History of consuming cigarette is present, forabout 20 years, about 1 box per day.
There isnt exposure of wood dust.
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General Status General appearance : Moderate ill
Consciousness : Composmentis Cooperative
Blood pressure : 120/70 mmHg
Pulse : palpable, regular, 82 times per minute
Respiration : abdominotoracal, regular, 19
times per minute Temperature : 36,90C
Height : 162 cm
Weight : 54 kg
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Systemic Examination Eyes : Anemic conjunctiva (-), icteric sclera (-
)
Neck : Coli (d) region, level II-III: mass (+),size: 4x4x1 cm, solid, fixed, tenderness (-),hyperpigmentation (+)
Pulmo : normal
Cardio : normal
Abdomen : normal
Extremities : warm acrals, good perfusion
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Auricle
Congenital abn. - -
Trauma - -
Inflammation - -
Metabolic abn. - -
Pain tensile - -
Tragus tenderness
-
-
Ear canal
Wide + +
Narrow
Hyperemia
Edema
Mass
Discharge/Cerum
en
Smell - -
Color -
-
Amount - -
Type - -
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Tympani Membrane
Intact
Color grey white
Light reflex
-
+
Bulging - -
Retraction - -
Atrophy - -
Perforation
Numbers
-
-
Type
Quadrant
Edge
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Mastoid Inflammation - -
Fistula - -
Scar - -
Tenderness - -
Tap pain - -
Tuning fork test
Rinne - +
Schwabach longer same
Weber right lateralization
Conclusion Conductive hearing loss
Audiometry
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Nose
External nose
Deformity - -
Congenitalabn.
-
-
Trauma - -
Inflammation - -
Mass -
-
Paranasal Sinuses
Tenderness - -
Tap pain - -
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Anterior Rhinoscopy
VestibulumVibrissae +
+
Inflammation - -
Nasal cavity
Plenty wide + +
Narrow
Wide
Discharge
Location - -
Type
Amount
Smell
Inferior concha
Size eutrophy eutrophy
Color pink
pink
Surface sleek sleek
Edema - -
Media concha
Size eutrophy eutrophy
Color pink pink
Surface sleek sleek
Edema -
-
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Septum
Straight/
Deviation
- -
Surface - -
Color - -
Spine - -
Crest - -
Abscess - -
Perforation - -
Mass
Location - -
Shape
Size
Surface
Color
Consistency
Easily swayed
Constrictor effect
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Posterior Rhinoscopy
Choana
Plenty wide
Narrow + +
Wide
Mucous
membrane
Color
pink
pink
Edema - -
Granulation
tissue
- -
Inferior concha
Size eutrophy eutrophy
Color pink pink
Surface sleek sleek
Edema - -
Adenoid Present/Not not not
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Mouth of
Eustachian tube
Closed by
discharge
closed by
mass
-
Mucous edema
-
-
Mass
Location nasopharynx dextra
Size Closing almost half of
nasopharynx
Shape irregular
Surface irregular
Post nasal dripPresent/Not not not
Type
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Palatum molle +
pharyngeal arch
Symmetrical/Not symmetrical symmetrical
Color pink pink
Edema - -
Spotted/Exudate -
-
Pharyngeal wall
Color pink pink
Surface sleek
sleek
Tonsil
Size T1 T1
Color pink pink
Surface sleek sleek
Mouth of cripti
no widening
no widening
Detritus - -
Exudate - -
Adhesion to the
pillars
- -
Peritonsil
Color pink pink
Edema - -
Abscess -
-
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Tumor
Location - -
Shape
Size
Surface
Consistency
TeethCaries/radix + +
Impression bad hygiene bad hygiene
Tongue
Color pink-red
pink-red
Shape normal Normal
Deviation - -
Mass - -
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Indirect Laryngoscopy
Epiglottis
Shape omega omega
Color pink pink
Edema -
-
Edge flat flat
Mass - -
Arytenoid
Color white white
Edema - -
Mass -
-
Movement normal normal
Ventricular band
Color pink pink
Edema - -
Mass - -
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Plica vocalis
Color white white
Movement - -
Medial edge - -
Mass white white
Subglottis/
trachea
Mass - -
Discharge - -
Pyriform sinus
Mass - -
Discharge - -
ValleculaMass - -
Discharge - -
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Lymph Nodes Examination
By the inspection, a lymph node can be
seen in coli (d) region, level II-III By the palpation, a mass of lymph node was
present, size: 4x4x1 cm, solid, fixed,tenderness (-)
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History Patient has noticed as a nasopharyngeal
carcinoma non keratinizing stage IV B (T2N3aMO)
durante 20thRadiotherapy, the laboratoryfinding has informed that Hb: 9,6 g/dl and hesuggested to do blood transfusion.
Patient has done the chemotherapy for twice.
Lump in the right side of neck since 5 monthago, and getting smaller after the radiotherapy.
The right ear feels blocked since 4 month ago.
Intermittent headache in the right side of headsince 2 month ago.
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Physical Examination Ear (d) : tympani membrane: grey, light reflex (-),
rinne: (-), weber: right lateralization, swabach:
longer than the examiners Ear (s) : tympani membrane (s): white, light reflex
(+),rinne: (+), weber: right lateralization,swabach: same as the examiners
Nose : posterior rhinoscopymouth ofEustachian tube (d): closed by mass, mass: innasopharynx dextra, size: closing almost half ofnasopharynx, shape: irregular, surface: irregular.
Throat : normal
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Working Diagnosis
Nasopharyngeal Carcinoma Non-Keratinizing Stage IV B (T
2N
3aM
O) Durante 20th
Radiotherapy Pro Transfusion Susp.Intracranial Metastasis
Additional Diagnosis
Conductive Hearing Loss
Differential Diagnosis
-
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More Examination CT-scan: nasopharyngeal tumor spreading
to hypopharynx dextra
Histopatology: squamous cell carcinoma ofnasopharynx non-keratizing welldifferentiated.
Suggested Examination Periphery blood examination
Brain CT-Scan
Audiometry
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Therapy Dexamethasone pre transfusion (2 x 1 ampul 5 mg)
Transfusion of 2 units PRC (2 x 1 unit)
Radio-chemotherapy
Prognosis Quo ad sanam : dubia at malam
Quo ad vitam : dubia at malam
Quo ad fungsionam : dubia at malam
Education To continue the therapy regularly.
Stop smoking and drinking alcohol, and having ahealthy life: doing exercise 3-5 times in a week,consuming vegetables and fruits.