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AN ELEVEN YEARS OLD BOY WITH AURICULAR

KELOID

By:
Fitria Dewi L G99142134
Muhammad Faizal G99142129
Rosi Dwi M G99161085

Supervisor : dr. Amru Sungkar, Sp. B, Sp.BP-RE (K)

Periode : 26 September 2016 – 1 October 2016


Patient Status
 Name :M

 Age : 11 years old

 Sex : Male

 Address : Boyolali

 Religion : Islam

 No. RM : 01264270

 Date of admission : 10 September 2016


CHIEF COMPLAINT

Lump at left ear


CURRENT HISTORY

Patient come to the hospital with complaint a lump


at his left ear that become bigger. He felt the lump
grow since 2 years ago, after he recovered from
burn. Bumps small beginning, gradually enlarged.
Patients had surgery on the ear in april 2016. From
the recognition of the patient during surgery, not all
lumps are drawn. Currently the patient feels a lump
back enlarged.
PREVIOUS HISTORY FAMILY HISTORY

Operation history (-) Same complaint (-)

Trauma history (-)

Same complaint (-)

Alergic history (-)


SISTEMIC ANAMNESIS
 Eyes : normal
 Ear : lump at left ear
 Mouth : normal
 Respiration system : normal
 Cardiovasculer system : normal
 Gastrointestinal system : normal
 Muskuloskeletal system : normal
 Genitourinaria system : normal
Physical Examination
 General status : Compos mentis, GCS E4V5M6,
Good Nutrition
 Vital sign :
BP : 110/70
N : 88 x/minute, regular,
RR : 22 x/minute
T : 36.7o C per axillar
GENERAL SURVEY
Neck : normal
Thorax
 Inspection : movement of hemithorax symetric
dextra sinistra, ictus cordis is not
visible
 Palpation : fremitus tactil symetric dextra
sinistra
 Percusion : sonor/sonor, heart border normal
 Auscultation : vesicular (+/+) normal, additional
sound (-/-), heart sound normal,
regular, abnormal sound (-)
GENERAL SURVEY
Abdomen
 Inspection : distended (-)
 Auscultation : bowel sound (+) normal
 Percusion : tympanic
 Palpation : pain (-), defense muscular (-)

Genitourinaria : normal

Musculoskeletal : normal

Extremity : normal
LOCAL STATUS
Ear Regio
 Inspection : lump (+), scar hipertrofi (+)
LOCAL STATUS
ASSESMENT I

Scar hypertrofi et causa post combutio


PLANNING I

 Inj Cefotaxim 500mg/12 h


 Inj metamizol 500mg/12 h
 Ranitidine 50mg/12 h
 Infus D1/4 NS 20 tpm
 Eksisi Keloid at 23/9/2016
Blood Examination
Pemeriksaan 20/9 Satuan Rujukan

Hb 10,7 g/dl 10.8-14.7

Hct 45 % 33-45

AE 4,7 106 / L 4,5-5,9

AL 8,8 103 / L 4,5-11,0

AT 293 103/ L 150-450


Assesment II

 Keloid regio auricular sinistra post ecsision


Planning II

Pro ecsision
Post Ecsision

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