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    Case Study: Acute Tonsillo Pharyngitis Exudative

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    Nicoh Avila
    The document describes a case study of a 20-year-old male patient admitted with acute tonsillopharyngitis. He presented with a sore throat, fever, and difficulty swallowing. On examination, his tonsils were enlarged with exudates and he had cervical lymphadenopathy. Laboratory tests found an elevated white blood cell count and positive strep test, indicating active streptococcal infection. He underwent a bilateral tonsillectomy and uvulopalatopharyngoplasty.

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    Case Study: Acute Tonsillo Pharyngitis Exudative

    Uploaded by

    Nicoh Avila
    25 views4 pages
    The document describes a case study of a 20-year-old male patient admitted with acute tonsillopharyngitis. He presented with a sore throat, fever, and difficulty swallowing. On examination, his tonsils were enlarged with exudates and he had cervical lymphadenopathy. Laboratory tests found an elevated white blood cell count and positive strep test, indicating active streptococcal infection. He underwent a bilateral tonsillectomy and uvulopalatopharyngoplasty.

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    The document describes a case study of a 20-year-old male patient admitted with acute tonsillopharyngitis. He presented with a sore throat, fever, and difficulty swallowing. On examination, his tonsils were enlarged with exudates and he had cervical lymphadenopathy. Laboratory tests found an elevated white blood cell count and positive strep test, indicating active streptococcal infection. He underwent a bilateral tonsillectomy and uvulopalatopharyngoplasty.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    25 views4 pages

    Case Study: Acute Tonsillo Pharyngitis Exudative

    Uploaded by

    Nicoh Avila
    The document describes a case study of a 20-year-old male patient admitted with acute tonsillopharyngitis. He presented with a sore throat, fever, and difficulty swallowing. On examination, his tonsils were enlarged with exudates and he had cervical lymphadenopathy. Laboratory tests found an elevated white blood cell count and positive strep test, indicating active streptococcal infection. He underwent a bilateral tonsillectomy and uvulopalatopharyngoplasty.

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    © All Rights Reserved
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    of 4

    CAPITOL MEDICAL CENTER COLLEGES INC.

    CASE STUDY
    ACUTE TONSILLO PHARYNGITIS
    EXUDATIVE

    CORRAL, Priscilla Chantal M.

    07/30/2010

    MRS. ANGELES

    I.

    Clinical Instructor

    PERSONAL DATA:
    Name:
    E. A. J. C.
    Address: Umbel st. Roxas District QC
    Age: 20 years old
    Sex: Male
    Civil Status: Single
    Religion: Roman Catholic
    Birthday: March 24, 1990
    Birthplace: Manila
    Room no.: 551
    Hospital no.: 320035
    Attending Physician: Dr. Romulus Instrella
    Medical Diagnosis:
    ACUTE TONSILLO PHARYNGITIS EXUDATIVE
    Peritonsillar abscess, chronic hypertrophic tonsillar,
    to consider Obstructive Sleep Apnea
    o Chief complaint: Sore throat
    o Procedure Done: Bilateral Tonsillectomy with
    Uvulopalatopharyngoplasty
    Surgeon: Dr. Romulus Instrella
    Anesthesiologist:
    Dr. Jose Acosta
    Scrub Nurse: Jesika Lopez, R.N.
    Circulation Nurse: Czarina Anne Abad, R.N.
    o
    o
    o
    o
    o
    o
    o
    o
    o
    o
    o
    o

    II.

    MEDICAL HISTORY
    A. History of Present Illness.
    2 days prior to admission, the patient developed fever
    which was an associated symptom. He took paracetamol to
    attend temporary relief. 1 day prior to admission, the
    patient complained of sore throat and then was give care
    at emergency room. He was sent home with medical
    prescription of paracetamol and Amoxiclav. On the day of
    admission, patient consulted an attending physician due to
    the persistency of symptoms, he was complaining about
    dysphagia and dyspnea and so he was admitted.
    B. Past Medical History
    The Patient has no known allergies. He does not have
    history of hospitalization. He has no experience of injuries,
    accidents or other considerable diseases.
    C. Family Medical History

    The patients family background use to have asthma on the


    paternal side but doesnt have any diseases or complications
    on the maternal side.
    D. Social & Environmental History
    The patient is not smoking and not even considering
    alcoholic beverages.

    III. LABORATORY / DIAGNOSTIC EXAMINATION


    Laboratory

    Result

    Normal Value

    Interpretation

    COMPLETE BLOOD COUNT

    Hemoglobin
    Hematocrit
    Erythrocytes
    Platelets
    Total WBC

    149 g/L
    0.45 g/L
    528 10^12/L
    299 10^9/L
    18.010^9/L

    145 160 g/L


    0.40-0.48
    4.5-5.0 for male
    150-440
    5.0-10.0

    ASO Titer

    200 IU/ml

    0.00 200.00
    IU/ml

    Normal
    Normal
    High
    Normal
    High (Presence of
    Infection)

    Positive
    (Active Streptococcal
    Infection)

    IV. PHYSICAL EXAMINATION


    Body Part

    Mouth and
    Neck
    -Tonsils
    -Lymph
    nodes
    Airways
    -Breath
    sounds

    Normal
    Findings
    -red, not
    swollen

    Actual Findings
    -hypertrophic with
    exudates

    -cervical

    lymphadenopathy

    -clear, no
    sounds
    heard. No
    crackles,
    wheezes or
    murmurs.

    (+) murmurs,
    presence of breath
    sounds

    Interpretation
    -sign of
    infection
    -sign of
    infection
    -obstruction
    on the airways

    V.

    PATHOPHYSIOLOGY
    1. Virus; 2. Bacteria;
    3. Group A beta
    hemolytic streptococcus

    Release of chemical
    mediators

    Tissue

    (histamine, prostaglandin,

    Vasodilatio

    Phagocytic
    action

    Edema

    Occlusion of almost half of


    the mouth

    Swelling

    1. Pain; 2. Fever; 3. Redness; 4. Exudates; 5. Sore throat; 6. Odynophagia; 7. Dysphagia;


    8. Otalgia; 9. Dyspnea

    Nursing diagnosis:
    Acute pain related to
    compression of nerve
    endings as evidenced
    by pain scale of
    Management:
    Rest
    Analgesics
    Decrease stimulation

    Nursing Diagnosis:
    Hyperthermia related
    to infection as
    evidenced by
    temperature of over
    37.5

    Nursing diagnosis:
    Imbalance
    nutrition
    related
    Ineffective airway
    clearance
    to obstruction of
    related to retained
    upper
    respiratory
    secretions as
    manifested
    by
    tract on cough.
    excessive sputum

    Management:
    Tepid sponge bath
    Cool environment
    anti-pyretics

    Management:
    Management:
    Mucolytic Soft diet; liquid
    diet.
    Chest physiotherapy
    Increase Oral fluid intake
    Position in semifowlers

    Nursing
    diagnosis
    Ineffecctive
    airway
    clearance
    related to
    airway
    obstruction
    Management:
    Corticosteroid
    s
    anti-

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