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E.N.T CASE

Puti Dwi Ginanti

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IDENTITY

Tn. A

31 years old

S1 Tabloid editor, since 4 years ago

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ANAMNESIS

Main complain: congestive nose

Other complains: rinorhea, post nasal drip,reduce ability to smell, headache, snorring

History of Present Illness Patient come to ENT clinic with main complain

congestive nose since 4 month ago he also complain ofwatery rinorrhea, post nasal drip , reduce ability to

smell, headache and snorring There is no trauma, foreign object are left, he also feel

sometime fullness of his ear, but there is no secret outof his ear.

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Past Medical History

Had feel like this before

Never been in hospital for serious disease

Allergic (+)

Family Medical History

No one feel like this

Parents dont have problem with ear, nose, and

throat

Parents have allergic (+)

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Psychology, Social, and Economic History

Live in with his wife and one children

House with good ventilation

He doesnt smoke

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OCCUPATIONAL ANAMNESIS

Occupation Material Workplace Years of

Service

Editor Computer,

stationeryTabloid Pulsa 4years

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Potential Hazard

Physics

Temperature

vibration

Chemical

Pollution

Biological :

Bacteria,

virus, fungi

Ergonomi

Awkward

position

Repetitivemovement

Psikososial

exhausted

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Physical Examination

Nose : Cavum

nasi dextra

Single grey

polipoid masses

in the nasal

cavity, mobile

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Working Diagnose

Polip Nasi Dextra

Diferential Diagnose

Nasal papiloma,Konka hipertrofi

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Diagnosis of occupational

Clinical

diagnosis

Anamnesis

Physicalexamination

Polip nasi dextra

Patient come to ENT clinic with main complain

congestive nose since 4 month ago he also

complain of watery rinorrhea, post nasal drip ,reduce ability to smell, headache and snorring

Nose : Cavum nasi dextra

Single grey polipoid masses in the nasal cavity,mobile

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Exposure in the

workplace

Physics : noistemperature, vibration

Chemical : pollution,

Biological : bacteria, viral, fungi

Ergonomic : awkward posture, repetitive movements

Psikosocial : stress at workplace, exhaustd

Evidence based The etiology of nasal polip is unknown, historically it has been

assumed that allergy predisposed to nasal polip because the

symptoms of watery rhinorrhea and mucosal swelling were

present in both diseases along with an abundance of eosinophils

in the nasal secretions

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Total duration of

exposure

4 years

Individual factor Allergic (+)

Other factor

outside work

No

Diagnosis of

occupational

Polip nasal dextra worst by work

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Health Category

Health Category

Fit with note

Prognosis:

Ad vitam : dubia ad bonam

Ad sanasionam : dubia ad bonam

Ad fungsionam : dubia ad malam

Okupasi: dubia ad bonam

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Treatment

Non medikamentosa:

Allergyc test

Biopsy

Surgery : ekstraksi polip nasi (polipektomi)

Medikamentosa:

Methyl prednisolon 2 x 16 mg

Rhinos 2x1

Nutriflam 2x1 tablet