sinus maksilaris akut sinistra

8/15/2019 Sinus Maksilaris Akut Sinistra

http://slidepdf.com/reader/full/sinus-maksilaris-akut-sinistra 1/11

LAPORAN KASUS

KEPANITERAAN KLINIK ILMU KESEHATAN THT-KL

RUMAH SAKIT UMUM DAERAH KUDUS

PERIODE 9 NOVEMBER – 12 DESEMBER 2015

SINUSITIS MAKSILARIS AKUT SINISTRA

Pembimbing :

Dr. Agus Sudarwi, Sp. THT-KL

Dr. Afif Zjauari, Sp. THT-KL

Dissn !"e# :

I$b%" A&i Ang'%

(0)15102*

+AKULTAS KEDOKTERAN

UNIVERSITAS TARUMANA,ARA

-AKARTA



LEMBAR PEN,ESA.AN

Lap!ra" Kasus

SINUSITIS MAKSILARIS AKUT SINISTRA

Te"%# &i&is/si/%n %&%:

D#s#$%#r &'()

Pembimbing:

dr. Agus Sudarwi, Sp.THT-KL

dr. Afif Zjauari, Sp.THT-KL

M#"g#*aui,

dr. Agus Sudarwi, Sp.THT-KL dr. Afif Zjauari, Sp.THT-KL

BA,IAN ILMU KESE.ATAN T.TKL

RSUD &'LOEKMONO.ADI3KUDUS



I IDENTITAS PASIEN

Na$a + N.A

U$ur + Tau"/#"is K#0a$i" + P#r#$pua"

Aga$a + Is0a$

P#1#rjaa" + 2uru pa%ri1

S*a*us + M#"i1a

A0a$a* + R#j!sari, Kudus

N!$!r 3M + 4&(555

II PEMERIKSAAN SUB-EKTI+

A4!%n%mnesis

Di0a1u1a" pada *a"gga0 &) N!6#$%#r &'() pu1u0 ((.' 7I2 di P!0i10i"i1 THT

RSUD dr. L!#1$!"!adi Kudus

Ke"#%n U4%m%

Pi0#1 d#"ga" i"gus 1#"*a0 1u"i"g 1#ijaua" da" %au

Ri%6%4 Pen6%/i4 Se/%'%ng

Pasi#" da*a"g 1# RSUD Kudus d#"ga" 1#0ua" pi0#1 s#ja1 ( $i"ggu a"g 0a0u, pi0#1

dirasa1a" *#rus, pasi#" $#"ga1u i"gus a"g 1#0uar %#war"a 1u"i"g 1#ijaua" d#"ga"

1!"sis*#"si 1#"*a0. I"gus a"g 1#0uar *ida1 dis#r*ai dara. Pasi#" juga $#"ga1u ada"a %au

*ida1 #"a1 *#r8iu$ !0#"a a"g dirasa1a" s#ja1 *i$%u0 pi0#1. K#0ua" juga dis#r*ai d#"ga"

idu"g *#rsu$%a*, 1#0ua" *#rsu$%a* dirasa1a" i0a"g *i$%u0 di idu"g"a a"g s#%#0a 1iri

%#rsa$aa" d#"ga" *i$%u0"a pi0#1, s#da"g1a" idu"g s#%#0a 1a"a" *ida1 *#rdapa* 1#0ua".

Pasi#" juga $#"g#0u1a" s#ja1 pi0#1 ia $#"ga0a$i sa1i* 1#pa0a, sa1i* 1#pa0a dirasa1a" i0a"g

*i$%u0, 1#0ua" dis#r*ai juga d#"ga" da#ra s#1i*ar pipi *#rasa "#ri s#ja1 pi0#1. Pasi#" juga

$#rasa1a" s#p#r*i ada"a 0#"dir a"g $#"ga0ir 1# *#"gg!r!1a". Pasi#" juga $#"g#0u

*i$%u0"a %a*u1 da" $#rasa s#di1i* $#ria"g. S#%#0u$ pasi#" %#r!%a* 1# RSUD pasi#" suda

%#r!%a* 1# pus1#s$as.

Pasi#" $#"a"g1a0 ada"a riwaa* sa1i* gigi s#%#0u$"a. K#su0i*a" saa* $#"#0a" da"

"#ri saa* $#"#0a" $aupu" suara s#ra1 pada *#"gg!r!1a" disa"g1a0. Pasi#" *ida1 $#$i0i1i

riwaa* 1#$asu1a" %#"da asi"g pada idu"g da" riwaa* *rau$a idu"g. Pasi#" $#"a"g1a0



Suu + 4,= !3

Ke%"% &%n Le#e'

K#pa0a + M#s!8#pa0

Ma*a + K!"ju"g*i6a a"#$is >-:-?, pupi0 is!1!r >@:@?

7aja + Si$#*ris.

L##r a"*#ri!r + Tida1 ada p#$%#sara" K2

L##r p!s*#ri!r + Tida1 ada p#$%#sara" K2

M"4 &%n ,igi

Mu0u* + Sia"!sis >-?, 1#ri"g >-?

Lida + N!r$a0, K!*!* >-?, *r#$!r >-?

igi + N!r$a0, 1ari#s >-?, ga"gr#" radi< >-?

S4%4s L!/%"is

1 Te"ing%

D#1s*ra Si"is*ra

Auri1u0a 2#"*u1 "!r$a0

N#ri *ari1 >-?

O#d#$ >-?

2#"*u1 "!r$a0

N#ri *ari1 >-?

O#d#$ >-?

Pr#auri8u0a 2#"g1a1 >-?

N#ri *#1a" *ragus >-?

Bis*#0 >-?

A%s#s >-?

N#ri *#1a" *ragus >-?

Bis*#0 >-?

A%s#s >-?

R#*r!auri8u0a N#ri *#1a" >-?

Ed#$a >-?

Hip#r#$is >-?

N#ri *#1a" >-?

Ed#$a >-?

Hip#r#$is >-?

Mas*!id 2#"g1a1 >-?

N#ri *#1a" >-?

Hip#r#$is >-?

2#"g1a1 >-?

N#ri *#1a" >-?

Hip#r#$is >-?



3AE S#ru$#" >-?

Hip#r#$is >-?

Ed#$a >-?

S#1r#* >-?

3!rpus A0i#"u$ >-?

S#ru$#" >-?

Hip#r#$is >-?

Ed#$a >-?

S#1r#* >-?

3!rpus A0i#"u$ >-?

Memb'%n Tim%ni

D#1s*ra Si"is*ra

P#rf!rasi >-? >-?

3!"# !f 0ig* >@? ara ja$ ) >@? ara ja$ 4

7ar"a Pu*i $#"g1i0a* s#p#r*i

$u*iara

Pu*i $#"g1i0a* s#p#r*i $u*iara

2#"*u1 3#1u"g 3#1u"g

PEMERIKSAAN RUTIN K.USUS TELIN,A : Ti&%/ &i"%//%n

2 .IDUN, DAN SINUS PARANASAL

P#$#ri1saa" Ru*i" U$u$ Hidu"g

De/s4'% Sinis4'%

Ben4/ N!r$a0 N!r$a0

Se/'e4 S#r!$u1!us Mu1!puru0#"

K!n/% N%si Me&i% Mu1!sa $#ra $uda,

ip#r*r!fi >-?

Mu1!sa $#ra $uda,

ip#r*r!fi >-?

K!n/% N%si In7e'i!' Mu1!sa $#ra $uda,

ip#r*r!fi >-?

Mu1!sa $#ra $uda,

ip#r*r!fi >-?

Me%4s N%si Me&i% S#1r#* >-? s#r!$u1!us

Pus >-?

ip#r#$is >-?

Se/'e4 8 m/!'"en

Ps 8

#ie'emis 8

Me%4s N%si In7e'i!' M#ra $uda

Massa a%"!r$a0 >-?

M#ra $uda

Massa a%"!r$a0 >-?

Se4m D#6iasi >-? D#6iasi >-?

M%ss% >-? >-?



Peme'i/s%%n R4in K#ss .i&ng

Tes N6e'i Sins P%'%n%s%"

De/s4'% Sinis4'%

In7'%!'bi4% N#ri T#1a" >-?, N#ri 1#*u1 >-? N6e'i Te/%n 83 N6e'i /e4/ 8

S'%!'bi4% N#ri T#1a" >-?, N#ri 1#*u1 >-? N#ri T#1a" >-?, N#ri 1#*u1 >-?

Regi! +'!n4%" N#ri T#1a" >-?, N#ri 1#*u1 >-? N#ri T#1a" >-?, N#ri 1#*u1 >-?

;%n4s Me&i% N#ri T#1a" >-?, N#ri 1#*u1 >-? N#ri T#1a" >-?, N#ri 1#*u1 >-?

Tes P'!6e/si Sins P%'%n%s%" 8T'%nsi"min%si

Di%7%n%s/!i De/s4'% Sinis4'%

Pii< ;%nin% K#sura$a" >-? Kes'%m%n 83 4%m%/

/es'%m%n &i m%/si"%'is

/i'i

Regi! 7'!n4%" K#sura$a" >-? K#sura$a" >-?

S'%!'bi4% K#sura$a" >-? K#sura$a" >-?

* TEN,,OROK

P#$#ri1saa" Ru*i" U$u$ T#"gg!r!1a"

Mu1!sa %u1a0 M#ra $uda

i"ggi6a M#ra $uda

igi g#0igi ga"gr#"# >-?, 1ari#s >-?

Lida M#ra $uda

Pa0a*u$ Duru$ C Pa0a*u$ M!00# U01us >-?, ip#r#$is >-?

Bari"g Mu1!sa ip#r#$is >-?, s#1r#* >-?

T!nsi"

TONS De/s4'% Sinis4'%

U/'%n T( T(

K'i4% Tida1 $#0#%ar Tida1 $#0#%ar

Pe'm/%%n Ra*a Ra*aDe4'i4s >-? >-?



=%'n% M#ra $uda $#ra $uda

Pe'i4!nsi" A%s#s >-? A%s#s >-?

O'!7%'ing

Or!fari"g

Pa0a*u$ M#ra $uda

Mu1!sa M#ra $uda

Di"di"g p!s*#ri!r !r!fari"g P!s4 n%s%" &'i 8

Pemeriksaan Rutin Khusus Tenggorok + *ida1 di0a1u1a" 1ar#"a *ida1 ada i"di1asi

N%s!7%'ing

o Dis8arg# +

o Mu1!sa + Tida1 di0a1u1a" p#$#ri1saa"

o Ad#"!id +

o Massa +

L%'ing!7%'ing

o Mu1!sa + Tida1 di0a1u1a" p#$#ri1saa"

o Massa +

L%'ing

o Epig0!*is +

o P0i8a !8a0is + Tida1 di0a1u1a" p#$#ri1saa"

o Massa +



IV PEMERIKSAAN PENUN-AN,

o -f!*! p!0!s SPN + p!sisi wa*#rs, da" 8a0dw#00

o E"d!s8!p THT + si"us1!pi si"us $a1si0aris

o 3T S8a" SPN

o Ku0*ur s#"si*i6i*as

( RESUME

T#0a dip#ri1sa s#!ra"g pasi#" p#r#$pua" %#rusia *au" d#"ga"+

I Peme'i/s%%n sb>e/4i7

% Ke"#%n U4%m%

Pi0#1 d#"ga" i"gus 1#"*a0 1u"i"g 1#ijaua" da" %au

b Ri%6%4 Pen6%/i4 Se/%'%ng

o Pi0#1 d#"ga" i"gus 1#"*a0 1u"i"g 1#ijaua" s#ja1 ( $i"ggu a"g 0a0u

o Rasa "#ri di pipi 1iri >@?

o Hidu"g *#rsu$%a* >@?

o 2a*u1 >@?

o Sa1i* 1#pa0a >@?

o D#$a$ >@?

? RPD

−Riwaa* as$a >-?

−Riwaa* sa1i* gigi >-?

−Riwaa* a0#rgi >-?

−Riwaa* Hip#r*#"si >-?

−Riwaa* Dia%#*#s >-?

−Riwaa* $aag >-?

& RPK : Ke"#%n se'% 8



e Ri%6%4 S!si%" E/!n!mi : Kes%n e/!n!mi /'%ng

II Peme'i/s%%n Ob6e/4i7

% KU : 2ai1

b Ke%"% &%n Le#e' + Da0a$ %a*as "!r$a0

? Peme'i/s%%n '4in mm 4e"ing% : Da0a$ %a*as "!r$a0

& Peme'i/s%%n R4in /#ss 4e"ing% : Tida1 di0a1u1a" p#$#ri1saa"

e Peme'i/s%%n R4in Umm #i&ng:

o Mu1!sa+ ip#r#$is >-?

o K!"1a "asi $#dia+ ip#r#$is >-?

o K!"1a "asi i"f#ri!r+ ip#r#$is >-?

o Me%4s n%si me&i%: se/'e4 8 m/!'"en3 s 83

#ie'emis 8

o M#a*us "asi i"f#ri!r+ s#1r#* >-?

7 Peme'i/s%%n '4in /#ss #i&ng:

o Sins P%'%n%s%"

o Tes '!6e/si n6e'i &i in7'%!'bi4% sinis4'%:

n6e'i 4e/%n 83 n6e'i /e4/ 8

o Di%7%n!s/!i: 4%m%/ /es'%m%n %&% m%/si"% sinis4'%

g Peme'i/s%%n '4in mm 4engg!'!/ : P!s4 n%s%" &'i 8

# Peme'i/s%%n '4in K#ss 4engg!'!/: Tida1 di0a1u1a"

p#$#ri1saa"

5 DIA,NOSIS BANDIN,

• Si"usi*is $a1si0aris a1u* si"is*ra

• Si"usi*is fr!"*a0is a1u* si"is*ra

• Si"usi*is #*$!ida0is a1u* si"is*ra

) DIA,NOSIS SEMENTARA



Si"usi*is $a1si0aris a1u* si"is*ra

@ DIA,NOSIS PASTI

2#0u$ ada

PRO,NOSIS

Du%ia ad %!"a$

9 PENATALAKSANAAN

1 Me&i/%men4!s% :

- A"*i%i!*i1

- K!r*i1!s*#r!id

- Mu1!0i*i1

- D#8!"g#s*a"

- A"a0g#*i1 da" a"*ipir#*i1

2 I'ig%si #i&ng &eng%n menggn%/%n N%;"

* +ESS 8+n?4i!n%" En&!s?!6 Sins S'ge'6

10 KOMPLIKASI

1 O'bi4%"

o S#0u0i*is !r%i*a

o A%s#s su%p#ri!s*#a0

o A%s#s !r%i*a

2 In4'%/'%ni%"

o M#"gi*is

o E"8#pa0i*is

o A%s#s !*a1

* Sis4emi/

o S#psis

sinus maksilaris akut sinistra

Documents