Case Report

Hari/ Tanggal : Saturday/ 13 Jul 8th 2017

Doctors on duty : Eko/Anto/Elniza-Loren/Tiwi
Consultant : Rossy Rosalinda MD, ORL

Department of Otorhinolaryngology Head and Neck Surgery

Faculty of Medicine Andalas University/Dr. M. Djamil Hospital
Padang
 Identity of Patient
Male, 34 year old

Chief Complaint
Bleeding came out from the left nostril 2 hours before
admission
 Medical History
Bleeding came out from the left nostril 2 hours before
admission
Previously 7 hours before admission, patient was
sleeping then suddenly bleeding came out from his left
nostril, about a half spoon. Patient went to Private
Hospital, and bleeding was stopped. Patient got
Transamin, Vitamin K, and Vitamin C orally, then the
patient was discharged. 2 hours ago there was bleeding
again, about a handkerchief, then patient went back to
Private Hospital, performed nasal packing then referred
to M Djamil Hospital
 Medical History
There was history of nasal obstruction
There was history of frequent sneezing when exposed by
dust, less than 4 days per week, didnt disturb his daily
activities
There was history of blowing the nose
There was no history scratching the nose
There was no history of nasal trauma
There was no decrease of smelling
There was no history of fullness or pain at the cheek or
forehead
 Medical History
There was no history of buzzing ear, no double vision,
no aural fullness
There was no lump at the neck
There was no history of prolonged wound bleeding
There was no history consuming antiplatelet drugs
There was no history of hypertension
There was no fever, cold and cough
 General Examination
General condition was moderately ill, compos mentis,
cooperative
BP : 120/90 mmHg
RR : 18 x/min
PR : 84 x/min
T : 36,7 0 C

Eye : conjunctiva : anemic (-/-)

 ENT Examination
Ear
Right ear : ear canal was wide, TM was intact, cone of
light (+), hemotympanum (-)

Left ear : ear canal was wide, TM was intact, cone of

light (+) , hemotympanum (-)
 ENT Examination
Nose
Right :
nasal cavity was narrow, inferior turbinate was
hypertrophy, middle turbinate difficult to evaluate,
septal deviation (+) cryst, clotting (+), active
bleeding (-), excoriation(-), laceration (-)
Left :
nasal cavity was narrow, inferior turbinate was
hypertrophy, middle turbinate difficult to evaluate,
septal deviation (+) cryst, clotting (+), active
bleeding (-), excoriation(-), laceration (-)
Nasoendoscopy Video
 Nasoendoscopic examination
Nasoendoscopy Right Left
Nasal cavity Narrow Narrow
Inferior Hypertrophy Hypertrophy
turbinate
Media turbinate Edema Edema
Middle meatal Opened Opened
Nasal Septum Deviation (+) cryst Deviation (+) cryst and
spine, contact with
inferior turbinate(-)
Discharge (-) (-)
Nasopharynx Mass (-), clotting (-), Mass (-), clotting (+),
PND (-) PND (-)
 ENT Examination
Throat
Pharyngeal arch was symmetric, uvula in the
midline, tonsil T1-T1, not hyperemic, posterior
pharyngeal wall was not hyperemic, clotting (-),
active bleeding (-)
Neck region :
No lymph node enlargement
 Laboratory Findings

Hb : 16,0 gr % PT : 11,3
Leuco : 8.890/mm3 APTT : 38,6
Thrombo : 277.000/mm3 RBG : 96 mg/dl
Ht : 48 %

Result : in normal limits

 Working Diagnosis

Working diagnosis Post epistaxis

Septal deviation
Suspiciuos Mild Intermittent
Allergic Rhinitis
ICD 10 Epistaxis (R04.0)
Septal deviation (J34.2)
Allergic rhinitis, unspecified
(J30.9)
 Management
Ciprofloxacin 2x500 mg (orally)
Cetirizine HCl 1x10 mg (orally)
Control to ORL-HNS out patient clinic 3 days later