parade 7 februari lengkappppppppppp.pptx

parade

1. 1 st patient

2. Identity Name : Mrs. Siti Mariam Gender : Female Date of Birth : November, 11th 1998/25 y.o . Medical Record : 2017665 Address : Bandung Occupation : Teacher Day of Surgery : Wednesday, Februari 8 th 2023

3. History Taking Chief complaint: Discharge From right ear The patient Complain discharge from right ear since 5 years ago. The last Complain of discharge was 2 months ago in right ear. The patient admitted that the discharge is yellow, thick, and smelly. The complain is also accompanied with discharge from behind the right ear and accompanied by decreased hearing in both ear. Complaints are not accompanied by nausea, vomiting, or headache. There is history of canal wall up right ear post operation day 1 year ago. no History of head trauma, stuffy nose, and allergies.

4. Physical Examination Right ear: ear canal not hyerpemic , discharge (-), Serumen (-), Tympanic membrane graft +, cone of light (-), fistula retroauricula + Left ear : ear canal not hyerpemic , discharge (-), Serumen (-), Tympanic membrane intact, cone of light (-), retroauricula not hyperemic AD AS

5. Physical Examination AD AS

6. Pure Tone Audiometry 47.5 dB 37.5 dB

7. Laboratory Finding 28/12/2022 Hb 13 Hct 40,2 Leu 8.720 Erit 8.61 Tro 217.000 PT/APTT/INR 14.2/33.60/1.00 Na/K 139/4.7 Ur/Cr 13.8/0.88 GDS 99 SGOT 21 SGPT 15 Rapid Antigen Sars Cov-2: Negatif

8. AXIAL CT SCAN View

9. Coronal CT Scan View

10. Diagnosis and Management WD/ Right Chronic Supurative Otitis Media with + Fistula retroauricula dextra Management under General Anesthesia - Right Ear Canal wall down + Timpanoplasty tipe 1 + Repair fistula retroauricula dextra

11. 2nd patient

12. Identity Name : Mr. Masron Gender : Male Date of Birth : Desember 3, 1975/ 47 y.o Medical Record : 0001593677 Address : Bandung Occupation : Employee Day of Surgery : Thursday, February 9 nd 2023

13. History Taking Chief complain: History of discharge from left ear The patient has a history of discharge from left ear since 3 years ago. The last Complain of discharge was 1 year ago. History of discharge from left ear was intermittent. Complain are accompanied by decrease hearing of the left ear. Complain are not accompanied by nausea, vomiting, or headache. There is no History of head trauma, stuffy nose, surgery, and allergies.

14. Left ear: ear canal not hyperemic, discharge (-), cerumen (-), Tympanic membrane subtotal perforation, cone of light (-), retroauricula not hyperemic Right ear: ear canal not hyperemic, discharge (-) cerumen (-), Tympanic membrane intact, cone of light (+), retroauricula not hyperemic Physical Examination AD S I AS S I A P A P

15. Pure Tone Audiometry 20 dB 28,75 dB

16. Laboratory Findings (27/1/2023) Hb : 15,6 gr/dL Ht : 45,6% Leucocyte : 7.620 /mm 3 Trombocyte : 217.000 /mm 3 PT : 14,8 sec APTT : 29,9 sec INR : 1,07 sec Blood Glucose : 97mg/dL

17. Stenver

18. Schuller

19. Diagnosis and Management WD/ Left Ear Chronic Otitis Media Management under General Anesthesia - Type 1 Tympanoplasty of the right ear

20. 3 st patient

21. Identity Name : Ms. Resty Gender : Female Date of Birth : August, 27 1997/ 25 y.o . Medical Record : 0002077093 Address : Bandung Occupation : Employee Day of Surgery : Friday, February 10 th 2023

22. History Taking Chief complain : History of D ischarge f rom L eft E ar The patient has a history of discharge from left ear since 2 years ago and the last complain is 1 year ago . Complain are accompanied by slightly decrease hearing of the left ear. Complain are not accompanied by nausea, vomiting, or headache. History of intermittent discharge from both ear when she was in childhood +. There are no History of head trauma allergies (-) . History of HT (-), DM (-)

23. Left ear: ear canal hyperemic, discharge (-), serumen (-), Tympanic membrane tympanic subtotal perforation, malleus incus intact, mobile +, cone of light (-), retroauricula not hyperemic Right ear: ear canal not hyperemic, discharge (-) serumen (-), Tympanic membrane retraction +, calsification +, cone of light (-), retroauricula not hyperemic AS Physical Examination AD S I A P S I A P

24. Pure Tone Audiometry 12,5 dB 21,5 dB

25. Laboratory Findings Hb : 13.4 gr/dL Ht : 38,5 % Leucocyte : 4.830 /mm 3 Trombocyte : 305.000/mm 3 PT : 14,6 sec INR : 1,05 sec Blood Glucose : 82 mg/dL

26. CT Scan Coronal

27. CT Scan Axial

28. Diagnosis and Management WD/ Left Ear Chronic Otitis Media Management under General Anesthesia - Type 1 Tympanoplasty of left ear

29. 4 st patient

30. Identity Name : Mrs. Siska Dwi Astiti Gender : Female Date of Birth : May 21th, 2001/ 21 y.o . Medical Record : 0002103747 Address : Bandung Occupation : Employee Day of Surgery : Monday, Februari 13 rd 2023

31. History Taking Chief complain : History of Discharge From right ear The patient has History of discharge coming from both right since 2 years ago. The last Complain of discharge was 2 month ago on both ears. Complains are accompanied with decrease of hearing on both ear. Complaints are not accompanied by nausea, vomiting, headache. There are no History of head trauma, stuffy nose, and allergies.

32. Left ear: ear canal not hyperemic, discharge (-), cerumen (-), Membran tympanic intact, calcification +, cone of light (-), retro auricula not hyperemic Right ear: ear canal not hyperemic, discharge (-) cerumen (-), tympanic membrane subtotal perforation, cone of light (-), retro auricula not hyperemic AS AD Physical Examination

33. Pure Tone Audiometry 47.5 dB 37.5 dB

34. Laboratory Findings (26/12/2023) Hb : 12.6 gr/dL Ht : 38.9% Leucocyte : 3.800 /mm 3 Trombocyte : 230.000 /mm 3 PT : 15.2 APTT : 34.30 GDS : 90 SGOT : 17 SGPT : 8 Ureum : 12.8 Kreatinin : 0.62 Natrium : 140 Kalium : 4.2

35. Stenver (17/01/2023)

36. Schuller (17/01/2023)

37. Diagnosis and Management WD/ Right Ear Chronic Otitis Media Management under General Anesthesia - Right Ear Tympanoplasty Type 1

38. 5th patient

39. Identity Name : Mrs. Della Amelia Gender : Female Date of Birth : August, 5nd 2003/ 19 y.o . Medical Record : 2091983 Address : Bandung Occupation : Student Day of Surgery : Tuesday, February 14 th 2023

40. History Taking Chief complain : History of Discharge From right ear The patient has History of discharge coming from right ear since 1 year ago. The last complain of discharge was 6 months ago on right ear. Complain are accompanied by decreased of hearing right ear. Complain are not accompanied by nausea, vomiting, headache. There are no History of head trauma, stuffy nose, and allergies. History of Hypertension (-), DM (-)

41. Left ear: ear canal not hyperemic, discharge (-), cerumen (-), Tympanic membrane intact, cone of light (-), retroauricula not hyperemic Right ear: ear canal not hyperemic, discharge (-) cerumen (-), Tympanic membrane subtotal perforation, cone of light (-), retroauricula not hyperemic Physical Examination AD S I AS S I A P A P

42. Pure Tone Audiometry 23,25 dB 16,75 dB

43. Laboratory Findings Hb : 16.0 gr/dl Ht : 46. 7 % Leucocyte : 5.370/ mm 3 Trombocyte : 260.000/ mm 3 PT : 13.5 sec INR : 0.95 sec APTT : 30.30 sec Glucose : 85 mg/dl

44. Stenver

45. Schuller

46. Diagnosis and Management WD/ Right ear Chronic Otitis Media Management under General Anesthesia - Left Ear Type 1 Timpanoplasty