Case report

Supervisor:
dr. Oscar Djauhari, Sp. THT-KL
Presented by:
Rizka Aulia Hermawati
2012730153

Identity
Name: Mr. G
Gender: Male
Age: 70 years old
Race: Sundanese
Occupation: retiree
Address: Siliwangi, Sukabumi

Chief complain: difficulty swallowing and hoarssness

Additional complaint: bad cough, enlarging lump in the

neck (3 months), fever, losing weight.

History
A 70 years-old male came with a chief complaint of difficult
swallowing that started first 3 weeks ago. The difficulty was
sudden and getting worse. He felt something was blocking his
throat. At first he could still eat soft food such as plain porridge,
but now he could only swallow liquid. The difficulty was not
accompanied by pain. Also since 2 weeks ago, accompanying
the difficulty of swallowing, he felt his voice became
progressively hoarse.
Since 1 years ago, he also complained of bad productive cough.
He could cough for half an hour during an attack. The cough
happened almost everyday. Sometimes he let out a yellowish
mucus, and sometimes it was white. He had cough up streaks of
blood around 3 months ago. Besides cough, he also experienced
feverish feeling, especially during the evening and the night. He
often woke up in the morning drenched in sweats.

History
The patient had lost 8 kg in weight in the previous 3
months even though there were no difference in amount
of food eaten. After a difficulty swallowing complaint, he
lost an additional 5 kg.
Around 3 months ago he felt a lump in his left upper neck
as big as papaya seed. The lump was getting bigger, and
now it was the size of table tennis ball. The lump was
painless.
There were no history of difficulty of breathing, chest pain,
loud breathing, nor snoring. He could recall any contact
with TB patient. He smoked 3 packs daily with no alcohol
or any drug abuse, before he get the ill.

History of family illness

Uneventful

Physical examination
General condition: appearing moderately ill
Blood pressure: 100/70 mmHg
Pulse: 80 beats per minute
Respiratory rate: 24 times per minute
Temperature : 37,40 C
Weight: 56 kg

ENT examination
Ear:
Right ear: Auricle normal, external auditory canal
hyperemia (-), Mass (-), laceration (-), secretion (-),
cerumen (-)
Tymphanic membrane:
Intact, hyperemia (-), bulging (-), light reflex (+)

Left ear: auricle normal, external auditory canal

hyperemia (-), edema (-), mass (-), laceration (-),
secretion (-), cerumen (-)
Tymphanic membrane: Intact,hyperemia (-), light
reflex (+)

Nose:
Right nose:
Mucous membrane: hyperemia (-), edema (-), laceration
(-), crust (-)
Inferior conchae: eutrophy
Septum: no deviation
Air passage: normal
Left nose:
Mucous membrane: hyperemia (-), edema (-), laceration
(-), crust (-)
Inferior conchae: eutrophy
Septum: no deviation
Air passage: normal

Oropharynx:
Posterior pharynx: hyperemia (-/-)
Palatine tonsils: T1/T1, Hyperemia (-), detritus (-)
Uvula: Symetrical
Dental: no abnormalities

Maxillofacial: symmetrical
Neck: 4x4 cm lymph node enlargement in the left upper lateral region,
painless, mobile
Lung: bronchial breath sound in the upper left lobe, wet rhonchi in the
upper left lobe
Heart: normal size from inspection, palpation, and percussion. Right
regular heart sounds from auscultation
Abdomen: supple, pain in palpation (-), peristaltic sound 15
times/minute
Liver: pain in palpation (-), enlagement (-), nodule (-), mass (-)
Back: costovertebral angle tenderness (-)
Extremities: warm, capillary refill time 2 seconds
Skin: dry, cracked lips

Resume
76 yeas-old male with dysphagia and dysphonia.
There were painless, enlarging mass in left upper
neck and history of productive cough with bloody
mucus, fever (+), night sweats (+), weight los. On
physical examination, patient appeared moderately ill
apart from normal vital signs. There was a 44 cm single,
painless, enlargement lymph node in the left upper lateral
region of neck. Bronchial breath sound and wet rhonchi on
the apex of superior left lobe. No sign of dehydration.

workup
Laboratory:
Complete blood count
ESR

Chest radiography
CT-scan head and neck
Sputum test
Laryngoscopy

laryngoscopy on the laryngitis

Tuberculosis

Working diagnosis
Dysphagia ec Esophagitis
Hoarssness ec Laryngitis TB
Tumor nasopharyngeal

Differential diagnosis
Dysphagia e.c. laryngeal cancer
nasopharyngeal cancer

treatment
Inpatient
IV line RL 20 dpm
Anti TB drugs if chest radiography support TB diagnosis
Rifampicin (10 mg/ kg BB, maksimal 600mg)
INH (5 mg/kg BB, maksimal 300mg)
Pirazinamid (35 mg/kg BB)
Etambutol (20mg/kg BB)

prognosis
Quo ad vitam: bonam
Quo ad functionam: dubia ad bonam
Quo ad sanactionam: dubia ad bonam

THANK YOU