PREFACE

Thanks to Allah SWT for helping and give uschance to finish this Scenario
A tutorial report on the 8th bloktimely. Shalawat and salamalways be with our
prophet Muhammad SAW and his family, friends, and followers until the end of
time.

We recognize that this tutorial report is far from perfect. Therefore we

expect constructive criticism and suggestions, in order to refine the next tasks.

In completing this tutorial task, we got a lot of help, guidance and advice.
On this occasion we would like to express our respect and gratitude to:

1. dr. Diani Wulan Dona as tutor of group 1

2. All of the members who involved in the making of this report

May Allah SWT give a reward for all the charity given to all those who
have supported us and hopefully this tutorial report, useful for us and the
development of science. May we always be in the protection of Allah SWT.
Amen.

Palembang, September 21st, 2017

Author

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 TABLE OF CONTENT

PREFACE .................................................................................................................. 1

TABLE OF CONTENT ............................................................................................. 2

CHAPTER I INTRODUCTION

1.1 Background ................................................................................................... 3

1.2 Purpose and Objectives .................................................................................4

BAB II DISCUSSION

2.1 Tutorial Data .................................................................................................5

2.2 Clarification of Terms ...................................................................................7

2.3 Problem Identification ..................................................................................8

2.4 Priority ..........................................................................................................9

2.5 Problem Analysis ..........................................................................................9

2.6 Conclusion ....................................................................................................30

2.7 Conceptual Framework .................................................................................30

BIBLIOGRAPHY ......................................................................................................31

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 CHAPTER I
INTRODUCTION

1.1 Background
Hematology and Lymphatic is the 8th blok in the third semester of
Competency Based Curriculum of Medical Education Faculty of Medicine,
Muhammadiyah University of Palembang.
In this occasion already implemented tutorial with case A 7 years old
boy brought by his mother to Puskesmas because there is a mass on the lower
right neck and getting worse over 4 days. The mass started as a small lump
that has enlarged to the size of a marble and now is becoming painful, and
warm to touch with overlaying redness. Also there is difficulty to move his
neck. Since 7 days ago, he has had a fever, runny nose, cough, and sore throat,
also complaining of swallowing food and drinking fluids. No voice alternate.
His mother give him a medicine, but the fever going down but then up again.
His past medical history: no one has the same complaint
Immunization history: Basic Immunization are complete
Growth and development history: normal
Diet history: same like common children
Physical Examiniation:
Vital sign: BP: 90/60 mmHg, P: 98x/m regular, RR: 24x/m, T: 37,6oC
Spesific Examination:
Head: Pupils are equal and reactive. Sclera is white and Conjunctiva are
clear. Pharynx is hyperemic. Both tonsil are T3-T3, erythromatous with
patches of exudates.
Neck (RegioColli Anterolateral Inferior Dextra):
Inspection: a mass with underlying erythema.
Palpation: a warm mass size 2 cm of diameter, tender, pain but no fluctuance
Thorax: Cor/Heart normal, no murmurs
Pulmo/Lungs normal
Abdomen: Normal, No hepatosplenomegaly

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 Extremities: Normal, Warm. Capillary refill time of one second
Laboratory
Hemoglobin 12 mg/dL. WBC: 16.000/mm3. Rate of sedimentation blood
10mm/h

1.2 Purpose and Objectives

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system at the
Faculty of Medicine, Muhammadiyah University of Palembang.
2. Can solve the case given in the scenario with the method of analysis and
learning group discussion.
3. Achieving the objectives of the tutorial learning method.

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 CHAPTER II
DISCUSSION

2.1 Data Tutorial

Tutor : dr. Diani Wulan Dona
Moderator : Arya Maulana
Secretary : Adliah Zahira Padya Sinta
Notulis : Rukmana Devi Lestari
Day and date : Monday, September 18th, 2017
(10.30 am -13.00 pm)
Wednesday, September 20th, 2017
(10.30 am – 13.00 pm)
Rule of tutorial : 1. Gadget should be nonactive or in silent mode.
2. Everyone in the group should express their opinion.
3. ask for permission if want to go outside.
4. Eating and drinking are not allowed in the room.

2.2 Scenario Case

“There is a mass on my boy neck”

A 7 year old boy brought by his mother to Puskesmas because there is a mass on
the lower right neck and getting worse over 4 days. The mass started as a small
lump that has enlarge to the size of a marble and now is becoming painful, and
warm to touch with with overlaying redness. Also there is difficulty to move his
neck. Since 7 days ago, he had a fever, runny nose, cough and sore throat, also
complaining of swallowing food and drinking fluids. No voice alternate. His
mother give him a medicine, but the fever going down but then up again.

His past medical history : never has complaint like this before

Family history: no one has the same complaint

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Immunization history : basic immunization are complete

Growth and development history : normal

Diet history : same like common children

Physical examination :

Vital sign: BP 90/60 mmHg, P 98x/m regular, RR 24x/m, T 37,6 oC

Specific examination :

Head : Pupils are equal and reactive. Sclera is white and conjunctiva are clear.

Pharynx is hyeperemic. Both tonsil are T3-T3, erythematous with patches

of exudate.

Neck : (Regio colli anterolateral inferior dextra)

Inspection : A mass with underlying erythema

Palpation : A warm mass, size 2cm of diameter, tender, pain but no

fluctuance

Thorax : Cor/ heart normal, no murmurs

Pulmo/ lungs normal

Extremities : Normal, warm. Capillary refil time of one second

Laboratory : Hemoglobin 12mg/dl. WBC 16.000/mm3 . Rate of sedimentation

blood 10mm/h.

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2.3 Term Clarification

No. Term Meaning

1. Mass Neck A lump or a group of particles attached to
each other on the neck
2. Exudate High protein fluid and cell debris that come
out of the blood vessels and deposited in
the tissues.
3. Sore Throat Pain in throat
4. Fever Increase in body temperature above normal
(37oC)
5. Pharynx Hyperemic Swollen blood abscess in the pharynx section
6. Erythematos Redness of the skin produced by capillary
congestion
7. Hemoglobin Oxygen-discontinuous pigment in
erythrocytes, formed by developing
erythrocytes in bone marrow
8. Tonsils A round and small tissue especially of
lymphoid tissue
9. Hepatosplenomegaly Enlarged liver and spleen
10. Murmurs Auscultation sounds, brief menstrual
abnormalities and short duration and come
from the heart and blood.
11. Regio colli anterolateral The lower front right neck
dextra
12. Pain But No Fluctuance Pain with a variation as about a fixed value or
mass, a wave liked motion.
13. Runny Nose Is excess drainage produced by nasal and
adjacent tissues and blood vessels in the nose.

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2.4 Problem Identification

1. A 7 year old boy brought by his mother to Puskesmas because there is a

mass on the lower right neck and getting worse over 4 days. The mass
started as a small lump that has enlarge to the size of a marble and now is
becoming painful, and warm to touch with with overlaying redness. Also
there is difficulty to move his neck
2. Since 7 days ago, he had a fever, runny nose, cough and sore throat, also
complaining of swallowing food and drinking fluids. No voice alternate.
His mother give him a medicine, but the fever going down but then up
again.
His past medical history : never has complaint like this before
Family history: no one has the same complaint
Immunization history : basic immunization are complete
Growth and development history : normal
Diet history : same like common children

3. Phyisical examination :

Vital sign: BP 90/60 mmHg, P 98x/m regular, RR 24x/m, T 37,6 oC

4. Specific examination :

Head : Pupils are equal and reactive. Sclera is white and conjunctiva are
clear.

Pharynx is hyeperemic. Both tonsil are T3-T3, erythematous with patches

of exudate.

Neck : (Regio colli anterolateral inferior dextra)

Inspection : A mass with underlying erythema

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 Palpation : A warm mass, size 2cm of diameter, tender, pain but no
fluctuance

Thorax : Cor/ heart normal, no murmurs

Pulmo/ lungs normal

Extremities : Normal, warm. Capillary refil time of one second

5. Laboratory : Hemoglobin 12mg/dl. WBC 16.000/mm3 . Rate of

sedimentation blood 10mm/h.

2.4 Priority

Number 1

2.5 Problem Analysis

1. A 7 year old boy brought by his mother to Puskesmas because

there is a mass on the lower right neck and getting worse over 4 days. The
mass started as a small lump that has enlarge to the size of a marble and
now is becoming painful, and warm to touch with with overlaying
redness. Also there is difficulty to move his neck
a) What is the anatomy of neck?
Organ in the neck :
1. Laryngopharynx
2. Larynx
3. Trakea
4. Oesophagus
5. Grandulathyroidea .
6. Grandulaparathyroidea

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7. Lymphonodus
(Snell, Richard. S. 2012)
Anatomy of neck :
1. Muscle
• M. platysma
• M. sternocleidomastoideus
• M. digastricus
• M. stylohyoideus
• M. sternohyoideus
• M. thyrohyoidus
• M.omohyoideus
• M. Scalenus
(Snell, Richard. S. 2012)

1. Arteries and veins

The main artery :artericarotiscommunis, a.carotisinterna
The main vein : vena jugularisinterna
2. Nerve :
Main nerve :nervusvagus X, N.accesorius XI, NervusHypoglossus
XII
Plexus cervicalis :nervusphrenicusnn cervical 3,4 dan 5
(Snell, Richard. S. 2012)

Lymphatic system :
The lymphatic system parallels the cardiovascular system (see the
images below). The lymphatic system is unique, in that it is a 1-
way system that returns lymph fluid via vessels to the
cardiovascular system for eventual elimination of toxic byproducts
by end organs, such as the kidney, colon, liver, skin, and lungs.

The lymphatic system consists of the following:

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 • Fluid, known as lymph
• Vessels that transport lymph
• Organs that contain lymphoid tissue (eg, lymph nodes,
spleen, and thymus)
(Snell, 2012)

b) What is the histology dan physiology lymph blend?

Answer:
Histology
The structure of the lymph nodes that showed chart structure of
lymph nodes which are divided into three main parts, namely: the
cortex, cortex, and medulla. The outer cortex: the outer cortex
surface there is a sinus subkapsularis, with the outer part that
bounded hoops and the inside lined the outer cortex. The cortex is
composed of a loose network of cells and macrophages, retikular
and retikulin fibers. Sinus subkapsularis sinus related medullaris
through sinus intermediate that goes with trabekula. The outer
cortex is formed of cells and fibers braided retikulin, full of B cells
in the lymphoid tissue of the cortex there is a round structure called
the lymphoid nodules. These nodules are rich in B lymphocytes
that reacts to the antigen, gets larger, and conduct proliferate
through mitosis, producing large cells, basofilik, with obvious core,
called imunosit. Some nodules showed the central part of the
terpulas lighter, called germinal centers. Germinal Center normally
shows a number of cells that contain a lot of bermitosis and
imunosit. These cells produce plasma cells producing antibodies.
Parakorteks: is a continuation of the outer cortex and contain
lymphoid nodules, a bit, but many contain lymphocytes t. Medulla:
comprising over korda medularis is the extension of the cortex in
the branches and contains lymphocytes B and a bit of a plasma
cell. Korda medullaris split by capillary structure similar to a width

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 that is called sinus limfoit medularis. This is sinus air spaces-
beratur no air spaces that contain lymph, such as sinus
subkapsularis sinus and trabekularis sinus, lymphoid medularis as
coated by retikular cells and macrophages. Cell and fiber retikulin
often menjebatani sinus – sinus in the form of loose braids.

(Junquera, 2006)
Lymph Gland Physiology
1. Limfonodi is an important part of the body's defense
mechanisms that spread throughout the body along the lymphatic
vessels. Most Limfonodi are found in the inguinal area and aksila.
2. Limfonodi liquid filter lymph function and memfagositosis
bacteria or foreign substance from liquid lymph. Macrophages are
reticular fibers woven in each node. So, when the liquid is filtered,
lymph nodules acts localize and prevent the spread of infection into
the general circulation. 3. Limfonoduli also create, store, and the
megalirkan of lymphocytes B and T lymphocytes and B
lymphocytes accumulates in. nodules limpoit limponodi, whereas
limposit T gathered under the nodules in the cortical or parakorteks
in the area. 4. Limfonoduli is also a place of antigen recognition
and activation of antigenic B lymphocytes that produce plasma
cells. Plasma cells then make and secrete specific antibodies
against specific antigens into blood and lymph vessels
(Guyton,2012)

c) What is the meaning there is a mass on the lower right neck

and getting over 4 days?
Answer :
The meaning is there is an Inflamantory neck masses with acute in
onset, the most common cause of neck masses is offten associated

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 with the infection on uper respiratory track like cought,fever and
sore throat.
(Jonas & Thandar. 2004 )
The meaning about there is a mass on the lower right neck and it
getting worse over 4 days is enlarged of Lymph nodes, enlarged
Lymph nodes cause by lymphocyte proliferation. Macrophage in
the follicle and sinus phagocyte , then the cell is hyperplasia
(Robbins, dkk., 2007)

d) What is the relation between age with the main problem?

Answer:
Lymphadenopathy more specify certain diseases in adulthood than
children because children are more easily react to form lymphoid
Hyperplasia. Lymphadenopathy in patients aged under 30 years at
80% of cases the cause is benign, while patients aged above 50
years old in 40% of cases the cause in benign.

e) What is the possibilities cause the mass on the lower right

neck?
Answer:

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 (Karnath, Bernard. 2005)

f) How is the pathophysiology the mass started as a small lump

that has enlarge to the size of a marble?
Answer:
infection may be caused by bacteria or viruses in the tonsils, the
bacteria or viru will proliferate to the nearest lymph nodes.
basically lymphocytes have two forms, derived from T cells and B
cells or bone marrow. the functions of B lymphocytes and derived
cells such as plasma cells, immunoglobulins, associated with
humoral immunity, as well as T lymphocytes play a role primarily

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 in cell-mediated immunity. these inflammatory cells will
phagocyte and will filter out the antigen that berproferasi it will be
more and more inflammatory cells that accumulate in the gland,
resulting in a lump.

g) What is the possibilities disease with lump in the neck?

Answer:
1. Congenital abnormalities: Cystic hygroma, krista ductus
thyroglosus
2. Infectious diseases
a. Viral infections: hepatitis, infectious mononucleosis
syndrome, AIDS, rubella
b. Bacterial infections: CSD, salmonella, staphylococci,
brucella, streptococcus, etc.
c. Fungal infections: koksidioidomikosis, histoplasmosis
d. Clamidia infection: lymphogranuloma, trachoma
e. Mycobacterial infection: TB, leprosy
f. Parasitic infections: tripanosomiasis, mycophilariasis,
toxoplasmosis
g. Syphilis, leptospirossis
3. Immunologic disease: RA, SLE, Dermatomyositis, drug
reactions (allopurinol, phenytoin, hydralazine, silicone implant)
4. Malignant disease
a. Haematologic: hodgkin's lymphoma, leukimian and T, B,
myeloid and acute and chronic lymphoma.
b. Metastatic tumors to the lymph nodes: melanoma, Kaposi's
sarcoma, Neuroblastoma, lung tumor, breast, prostate, kidney, head
and neck, gastrointestinal tract
5. Endocrine disease: hyperthyroidism
6. Lipid reserve disease: Gaucher and Niemann Pick

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 7. Idiopathic disease: Dermatopic lymphadenitis, lymphomatoid
granulomastosis, sarcoidosis, amyloidosis, multifokus Langerhans
cell granulomatosis
(Isselbacher, 2012).

h) What is the meaning of difficulty to move his neck?

Answer :
The meaning of difficulty to move his neck is the feel lumps in the
neck with the muscle relaxed and then because of the clumps the
muscle be contracted
(Browse,2005)

i) What is the meaning of the mass started as a small lump that

has enlarge to the size of a marble and now is becoming
painful, and warm to touch with with overlaying redness?
Answer :
Infection occurs Usually an acute or chronic infection. If acute
accompanied by pain, symptoms of fever, accompanied by reddish
color on the lump, cured with antibiotics, etc. If chronic is usually
a glandular tuberculosis, the lump of a size of a few millimeters
enlarges to centimeters, its treatment with anti-TB drugs takes 6-9
months. - Acute: Usually characterized by fever, banjolan pain and
redness. - Chronic: Usually on TB lymph nodes. The size of a
small bump is only a few milli-meters to centi-meters. Usually
amount to one lump, but can also directly some lumps and most
often located next to the left or right neck, sometimes sometimes
beside the left and right neck.

It is a clinical manifestation of Lymphadenitis, which is the

meaning of Lymphadenitis is the inflammation of the lymph nodes
with accompanied by signs of inflammation, such as dolor, calor,

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 rubor, and tumor. We can see the sign of inflammation on the
marble is becoming painful, warm to touch with overlying redness.

(Partridge, Elizabeth. 2016)

j) What is the organs can enlarge in the neck?
Answer :
The one of organ in the who can large is thyroid, this called Goiter
or ussualy people call it gondok. Goiter can be happen because
hipothyroidisme or because hiperthyroidisme, if caused by
hipothyroidisme it’s because deficiency iodium and if caused by
hypertiroidisme it’s because over secretion TSH because hipofisis
and over secretion from T3 and T4 because over growth
stimalation thyroid.
(Sherwood L. ,2014)

2. Since 7 days ago, he had a fever, runny nose, cough and sore throat,
also complaining of swallowing food and drinking fluids. No voice
alternate. His mother give him a medicine, but the fever going down
but then up again.

His past medical history : never has complaint like this before

Family history: no one has the same complaint

Immunization history : basic immunization are complete

Growth and development history : normal

Diet history : same like common children

a) What is the meaning of no voice alternate?

Answer :

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 Laryng is a sphincter for air way and laryng act as a producer
voice. No voice alternate indicate that no problem in laryng.
Because there is emphasis by mass.
(Snell,2011).

b) How is the pathophysiology of fever, runny nose, cough, and

sore throat?
Answer:
Fever: infected by Streptococcus Aureus enter to the upper of
respiratory tract leucocyte release endogen pyrogen like
IL1 is release send to hypothalamus hypothalamus
make prostaglandin raise the body temperature fever

Runny nose: infected by Streptococcus Aureus enter to the

upper of respiratory tract captured by APC macrophages cel
presented to Th cells. APC cells through the release of
interleukin I (II-1) and making a IgE IgE will bind the
existing APC cells Macrophages Infection causes inflammation
cause influ Ca ++ into cells and changes in cells that
decrease cAMP levels Cell Deganuration increased mucosa
runny nose

Cough : infected by Streptococcus Aureus enter the upper of

respiratory tract stimulated the nerves taked to the
cough center in hypothalamus back again by eferen nerves
to glottis glottis is close increased the pressure on
throat cough

Sore throat : infected by Streptococcus Aureus enter the upper

of respiratory tract Bacteria infected the epithelial epithelium

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 eroded inflammation the body responds by infiltration of
inflamed leucocytes enlarged tonsils sore throat.

c) What is the meaning of previous disease history, family history,

immunization history, history of growth and development, and
history of diet with connection to lump complaint?
Answer:
There is no correlation because all history shows normal

d) What are the cause of pain on swallowing?

Answer :
The main cause of hard to swallow is in the case because of
tonsilopharyngitis, the infections that makes tonsil inflamed. When
swallowing the food it will push the tonsil and make sense of pain
while eating or drinking
(Mandal., et al. 2009)

e) What is the meaning of his mother giving the medicine, the

fever goes down but rises back?
Answer :
Because the medicine that his mother given just cure the fever
(symptomatic) not the main symptoms which is in this case
tonsilopharyngitis caused by streptococcus aureus bacteria, so the
fever can rise up again and should be given antibiotic.

f) What are the possibilities of medications given by his mother?

Answer:
1. Salisilat, Salisilamid and Diflunisal
• Salisilat

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Salicylic acid (Acetosal or Aspirin) is used as antipyretic and anti-
inflamantory analgesk which classified in the free drug. Oher than
as a prototype, this drug is a standard in assessing similar effects.
• Salisimid
Salisimid is salicylic acid which show the analgetik and antipyretic
like Asetosal. The effect of Analgetik antipyretic of Salisimid is
more weak than Salisilat because Salisimid has first past
metabolism in the Intestinal mucous and just partly which enter
the circulation as an active substance.

• Diflunisal
Diflunisalis a derivate of difluorofenil from Salicylic acid, but in
vitro in vitro is not converted into Salicylic acid which has a
function as analgetic and anti- inflammatory.
2. Para Amino Fenol
Derivate of Para Amino Fenol is Fenastein and Asetaminofen.
Asetaminofen (paracetamol) is a Fenastein metabolism with
antipiretic effect. The antypiretic effect caused byAminobenzene
cluster.
3. Another analgesics and non-steroidal anti inflammatory
agents
• Mefenamic acid
Mefenamic acid used as analgetic, and less effective as anti-
inflammatory than aspirin. mefenamic acid is strongly bound to
plasma proteins.
• Ibuprofen
Ibuprofen as derivate of Propionat acid which has an analgesic
properties with not stong anti-inflammatory power, analgesic effect
is like aspirin.
(Tanu, 2012)

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g) How the pharmacokinetics and pharmacodynamics of the
drug?
Answer :
1. Ibuprofen
Pharmacokinetics:
Rapid absorbtion of ibuprofen through the stomach and maximum
levels in plasma are achieve after 1-2 hours. 90% of ibuprofen is
bound in plasma proteins. Excretion progresses rapidly throughthe
urine as a metabolite or conjuncture.

Pharmacodynamic:
This drug is analgesic with inflammatory power, that is not too
strong. The analgesic effect is same as aspirin.

2. Paracetamol (asetaminofen)
Pharmacokinetics:
Paracetamol is absorbed rapidly and completely through the gastro
intestinal tract. The highest concentration in plasma is achieved
within 0,5 hours and the half-life of plasma between 1-3 hours.
This drug is metabolized by liver microsomal enzymes. The drug is
spread through out of the body fluids, and excreted through by the
kidney.

Pharmacodynamics:
Paracetamol analgesic effect of eliminating or reducing mild to
moderatepain. Both of that can make lower body temperature. The
anti inflammatory effect is very weak, soits not used as
antireumatic.

(Nafrialdi: Setawati, A. 2007)

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 h) How the indication and contraindication of the drug?
Answer :
• Salisilat
Dose for adult:325-650 mg by orally every three until four hours,
and for children: 15-20 mg/kg given every four until six hours.
Based on the association of aspirin used for Reye’s syndrome,
aspirin is contraindicated as an antipyretic for children under 12
years. In the UK aspirin is prohibited used for children under16
years.
• Paracetamol
In indonesiathe used of paracetamol as ananalgesic and antypyretic
is replaced the used of salisilat. Paracetamol should not given for
long term because can cause analgesic nephropathy
(Tanu,2012).

3. Phyisical examination :

Vital sign: BP 90/60 mmHg, P 98x/m regular, RR 24x/m, T 37,6 oC

a) How is the interpretation of physical examination?

Answer :
Physical Category Interpretation
Examination
BP 80-100/50-70mmHg BP 90/60 mmHg
Interpretation :
Normal
HR <60 : Bradycardia HR :98 x/menit
60-100 : Normal Interpretation :
>100 : Tachycardia Normal

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 Temperature <36 o C :Hypothermia Temperature 37,9 o C
36-37,5 o C: Normal Interpretation :
37,5- 40 o C : Subfebris Subfebris
>40 o C : hyperthermia

RR 16-24x/menit RR 24x/menit
Interpretation :
Normal

b) How is the abnormal mechanism of physical examination?

Answer :
Infection inflammatory response microbials toxins act
as exogenous pyrogens stimulates endogenous pyrogen
release sitokin IL-1, IL-6, TNF and interferon
aracidonic acid release metabolized prostaglandin E2
Complex interaction between complement and prostaglandin
increased hypothalamus thermostat fever
(Price and Wilson, 2006).

4. Specific examination :

Head : Pupils are equal and reactive. Sclera is white and conjunctiva
are clear.

Pharynx is hyeperemic. Both tonsil are T3-T3, erythematous with

patches of exudate.

Neck : (Regio colli anterolateral inferior dextra)

Inspection : A mass with underlying erythema

Palpation : A warm mass, size 2cm of diameter, tender, pain but no

fluctuance

Thorax : Cor/ heart normal, no murmurs

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 Pulmo/ lungs normal

Extremities : Normal, warm. Capillary refill time of one second.

a) How is the interpretation of specific examination?

Answer :

Conditions Interpretation

Head  Pupils are equal and  Normal

reactive
 Normal
 Sclera is white
 Normal
 Conjungtiva are clear
 Abnormal
 Pharynx is hyperemic
 Abnormal
 Tonsil are T3-T3
 Abnormal
 Erythematous with
patches
Neck  A mass with underlying  Abnormal
erythema
 Abnormal
 A warm mass, size 2cm
of diameter, tender, pain
but no fluctuance
Thorax  Cor/heart  Normal
 Pulmo/lungs  Normal
Extremities  Normal, warm, capillary  Normal
refill time of one second

b) How is the abnormal mechanism of specific examination?

Answer :
Infected -> glands in the oral cavity and oropharynx including the
tonsils and the neck-specific KGB become the main defense for the

Page | 24
 body -> the immune reaction increases and inflammation reactions
occur -> cellular defense proliferation occurs in the Lymph gland
-> a lump due to follicular follicular hyperplasia-> follicles in the
limf and followed by the germinal center are increasingly actively
produce T cell lymphocytes and macrophages-> the Lymph gland
until the inflammatory response gets stronger -> causes the Lymph
gland to enlarge .
(Price, S, Lorraine, M., 2006)

5. Laboratory : Hemoglobin 12mg/dl. WBC 16.000/mm3 . Rate of

sedimentation blood 10 mm/h.
a) How is the interpretation of laboratory examination?
Answer :
Laboratory Based on Normal Range Interpretation
Scene
Hemoglobin 12 mg/Dl 10-16 mg/dL Normal
WBC 16.000/mm3 4.000- Leukocytocys
10.000/mm3
Sedimentation 10 mm/h 0-10 mm/h Normal
blood

b) How is the abnormal mechanism of laboratory

examination?
Answer :
Leukocytosis: Pathogen infection (bacteria / virus) → pathogen
spreads lymphogen to the nearest lymph tissue → inflammation
of the lymph nodes (in the neck and inguinal) → leukocyte
cells migrate to the inflammatory region → in response, an
increase in leukocytes
(Price, A and Wilson, L, M. 2006).

Page | 25
6. If sign and symptoms are linked
a) How to diagnose the disease in the case?
Answer :
• Anamnesis:
a. A 7 year old boy broughkt by his mother to Puskesmas
because there is a mass on the lower right neck and getting
worse over 4 days.
b. The mass started as a small lump that has enlarge to the size
of a marble and now is becoming painful, and warm to touch
with with overlaying redness.
c. difficulty to move his neck
d. Since 7 days ago, he had a fever, runny nose, cough and
sore throat, also complaining of swallow alternate
e. His mother give him a medicine, but the fever going down
but then up again.

• Physical examination: Temperature 37,6oC

• Spesific examination:
Head:
a. Pharynx is hyeperemic.
b. Both tonsil are T3-T3, erythematous with patches of
exudate.
Neck : (Regio colli anterolateral inferior dextra)
Inspection : A mass with underlying erythema
Palpation : A warm mass, size 2cm of diameter, tender, pain
but no fluctuance

b) What are the differential diagnosis of the disease?

Answer :

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Differential Lymphadenitis MalignantLymp Malignant CronicLimphoc
Diagnosis homa(Hodgkin) Lymphoma ytic Leukimia
(non Hodgkin) (CLL)
Age < 30 years old < 30 th&other> 20-39 years old Adultsage
50 years old (more on old
age)
Sex P>L P>L P<L P<L
Lymphadenop + + + +
athy Local dan generalisation
generalisation
Fever Subfebris + 38ºC Subfebris
Pain + - - -
Consistension Tender Heavy Heavy Heavy
of mass
Hepatospleno - + + +
megaly

c) What are the supporting examination of the disease?

Answer :
Supporting examination :
1. Culture of the lymphadenitis
2. FNAB (Fine Needle Aspiration Biopsy)
Can be examined Fine Needle Aspiration on the lump in the
neck to know the contents contained therein.
-USG = to know size, shape, micronodular picture, intronodal
necrosis and presence or absence of calcification
- CT-SCAN = can detect cervical lymph node enlargement
with diameter of 5mm or more.

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d) What is the working diagnosis?
Answer:
Lymphadenitis et causal Tonsillophayringitis

e) How to governance the disease in the case?

Answer :
Pharmacologycaltherapy:
1. Antibiotik (ex: amoxicilin) for causal treatment, with dose
for child >3months and <40 kg between 20-50 mg/kg/days
separate do see very 8-12 hours
2. Paracetamol for analgesic and antipyretic, with dose 150-
300mg/time, with maximum dose 1,2g/days
3. Salbutamol with dose3-4 times/days 2mg.

Treatment of Lymphadenopathy is based on the cause. Many

cases of KGB neck enlargement heal by it self and require no
treatment other than observation. Antibioticsshouldbegiven in
the presence of suppurative lymphadenitis commonly caused
by Staphylococcusaureus (group A). Provision of antibiotics in
10-14 days and this organism will give a positive response
within 72hours. Therapeutics failure requires reconsideration of
diagnosis and treatment.

Non- Pharmacologycaltherapy:
1. Prevention by maintaining health and body hygiene can
help prevent the occurrence of various infections.
2. To help reduce pain, can be compressed warm water or
given analgesic drugs.
3. Lymph node enlargement procedure based on the cause. if
the cause as the virus can heal itself and does not require any

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 treatment other than observation. treatment of lymph node
infections by bacteria is by oral antibiotics. when the cause of
Mycobacterium Tuberculosis is given anti-tuberculosis drugs.

f) What are the complications of the disease?

Answer :
1. abscesses
2. cellulitis (skin infections)
3. fistula formation (seen in lymphadenitis caused by TBC)
4. septic (septicemia or blood poisoning)

g) What are the prognosis of the disease?

Answer :
Bonam

h) What are the KDU of the case?

Answer:
4A
Doctor graduates are able to make clinical diagnoses and
manage the disease independently and thoroughly. 4A.
Competencies achieved at the time of graduation.
(Konsil Kedokteran Indonesia, 2012).

i) What are the Islamic value of the case?

Answer :
Al-Baqarah;153
O you who have believed, seek help through patience and
prayer. Indeed, Allah is with the patient.

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2.6 Conslusion

7-year-old boy has a lump in the right lower neck ± 2cm size increasingly
enlarged with complaints of pain, redness, fever, cough, and runny nose because
lymphadenitis et causa tonsillopharyngitis.

2.7 Conceptual structure

Streptococcus aureus bacteria infection

on tonsils & pharynx

Immune respons ↑

Inflammation of the lymph glands

Enlarged lymph nodes

Lymphadenitis colli dextra

Page | 30
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