Casewriteup Ent 110911092915 Phpapp01

8/12/2019 Casewriteup Ent 110911092915 Phpapp01

1/8

PATIENTS BIODATA

Name : Mr IR

Age : 30 years old

Sex : Male

Race : Malay

Registration no : AM 144046

Date of presentation : !"0#"010

PRESENTING COMPLAINT

$lecti%ely admitted for &ilaterally tonsillectomy and 'A(S) *nder +eneral Anast,esia-

HISTORY OF PRESENTING COMPLAINT

My patient .as pre%io*sly *ntil last year No%em&er .,ere ,e presented to a pri%ate clinic .it,

complaint of lo*d snoring- According to my patient/ ,e .as ,a%ing t,e c,ronic snoring pro&lem

for t,e past 10 years- o.e%er/ it &ecame a concern as ,is .ife complained t,at ,is snoring ,as

.orsened- ,ere .as significant ,istory of .eig,t gain- ,e snoring pro&lem progressi%ely

.orsened .it, ,is .eig,t gain- ,e snoring pro&lem sometimes ca*sed ,im to .a2e *p in t,e

middle of t,e nig,t d*e to s,ortness of &reat, .,ic, lead to fre*ent a.a2ening at nig,t .,ic,

affected ,is sleeping pattern- efore No%em&er last year/ ,is sleep cycle .as in order- (rior to

t,is/ ,e ne%er ,ad sleep apneic attac2s- o.e%er/ since No%em&er last year/ it ,appened

approximately t.ice in a .ee2/ t,*s ma2ing ,im *na&le to sleep so*ndly at nig,t- In addition/

t,ere is significant ,istory of di55iness- ,is di55iness occ*rs on and off- ,e d*ration is

%aria&le-

e also ,ad rec*rrent sore t,roat for t,e past 3 years .it, attac2 as fre*ent as once mont,ly

.it, or .it,o*t fe%er- If t,ere is ,istory of fe%er/ t,e fe%er .ill *s*ally &e a lo. grade fe%er

.,ic, is intermittent in nat*re .,ic, is relie%ed &y medication- ,e fe%er is not associated .it,

c,ills and rigors- ,e is no di*rnal %ariation in t,e fe%er- ,e sore t,roat episodes .ere *s*ally

preceded &y *pper respiratory tract infection symptoms- ,ere .as also ,istory of co*g,- D*ring

t,e day/ ,e *s*ally .ill &e let,argic/ sleepy and .ea2- ,*s/ ,is .or2 .as also affected-


2/8

o.e%er/ t,ere .as no pain/ morning ,eadac,e/ altered taste/ dryness/ trism*s/ dysp,agia/

odynop,agia/ ear ac,e or ot,er constit*itional sypmtoms- *rt,ermore/ t,ere .as no dysart,ria/

,oarseness/ stridor/ ,alitosis or constant t,roat clearing- ,ere .as no loss of appetite or loss of

.eig,t-

PAST MEDICAL AND PAST SURGICAL HISTORY

7nremar2a&le

DRUGS AND ALLERGIES

e is only allergic to seafood .,ere&y .,en ,e too2 seafood ,e .ill de%elop it,ciness all o%er

t,e s2in- )t,er.ise/ ,e ,as no ot,er 2no.n allergies-

FAMILY HISTORY

e ,as a positi%e family ,istory of atopy-is mot,er ,as $c5ema and ypertension .,ile ,is

yo*nger &rot,er ,as c,ild,ood ast,ma- )t,er.ise/ t,ere .ere no ot,er c,ronic medical illnesses-

SOCIAL HISTORY

Mr- I5nal Rafa is c*rrently single and .or2 as an instr*ment ser%ice tec,nician- is total

mont,ly income are approximately RM1/!00- e li%es .it, ,is friend in a single storey ,o*se in

',eras- e is a smo2er of # cigarretes per day for t,e past 10 years- )t,er t,an t,at/ ,e is a non8

drin2er-

PHYSICAL EXAMINATION

+ $N$RA9 $AMINAI)N

(atient loo2ed o&ese &*t generally ,e .as alert and comforta&le/ not pale loo2ing or ;a*ndice-

ital Signs:

(*lse Rate : !6 &eats"min/ reg*lar and good %ol*me


3/8

Respiratory rate : 0 &reat,s"min/ reg*lar

lood (ress*re : 130"#0 mmg

emperat*re : 3# o'

))RIN)9AR?N+)9)+I'A9 S?S$M

Oral Cavity

9ips and &*ccal m*cosal .ere .ell ,ydrated- Mo*t, opening .as good- ,ere .as no

,alitosis- Dentition .as good/ no missing teet, and &ledding g*ms- No tong*e atrop,y or

de%iation- ard palate appeared normal- ,ere .as no crac2s/ *lcers or masses seen in

t,e oral ca%ity-

Oropar!y"

,ere .ere &ilateral tonsils enlargement and t,ey appeared eryt,emato*s- o.e%er/ t,ere

.as no follicles or ex*date seen- @+rade 3- 7%*la .as slig,tly eryt,emato*s- Soft palate/

posterior p,aryngeal .all and &ase of tong*e appeared to &e normal- ,ere .as no *lcers/

s.elling or any ot,er masses seen- ,e larynx .as normal .it, mo&ile %ocal cords-

Ear

,e pinna and external a*ditory meat*s .ere normal &ilaterally- ,e tympanic

mem&rane appeared transl*cent pearly .,ite and no a&normalities .ere detected on &ot,

sides- RinneBs test .as positi%e on &ot, sides-


4/8

normal-

N$%&'

,e nec2 .as in normal attit*de- ,ere .as no noticea&le s.elling/ discoloration/ *lcer/

or prominent %eins- ,ere .as no temperat*re/ tenderness/ mass/ or lymp, node

enlargement- ,e trac,ea .as not de%iated-

No nodes or masses .ere palpa&le- No a&normalities .ere seen-

)$R S?S$MS

,e cardiorespiratory examination re%ealed normal c,est .it, %esic*lar &reat, so*nd and no

added ronc,i or crepitation- Apex &eat .as not dislocated and first and second ,eart so*nd .as

,eard .it, no m*rm*r- A&domen .as soft and non tender- ,ere .as no organomegaly-

SUMMARY

Mr IR/ a 30 year old Malay gentlemen presented .it, ,istory of c,ronic snoring for 10 years and

3 years ,istory of rec*rrent tonsillitis electi%ely admitted for &ilateral tonsillectomy .it, 'A(S)

*nder general anest,esia- (,ysical examination re%ealed grade 3 &ilateral ,ypertrop,ic

eryt,emato*s tonsils .it, eryt,emato*s *%*la-

DIAGNOSIS

',ronic onsillitis ca*sing o&str*cti%e sleep apnea

MANAGEMENT

ollo.ing a complete ,istory and p,ysical examination/ rele%ant &aseline in%estigations s,o*ld

&e carried o*t since patient .ill *ndergo an operation *nder general anaest,esia- $%en t,o*g, ,e

,ad no ot,er c,ronic medical illnesses/ patient still ,as e%ery possi&le ris2 especially since ,e is

o&ese-


5/8

IN>$SI+AI)N

1- *ll &lood co*nt

)&;ecti%e: 8 o c,ec2 for and infection and ameglo&in le%el since ,e ,ad &een

,a%ing rec*rrent tonsillitis

8 or pre8operation assessment

- Renal profile

)&;ecti%e: o assess renal f*nction @pre operation assessment

3- 9i%er f*nction test

)&;ecti%e: o assess renal f*nction @pre operation assessment

4- lood gro*ping cross matc,

)&;ecti%e: or preparation in case of any complication from t,e s*rgery .,ic, .ill need

&lood transf*sion-

=- ',est x8ray

)&;ecti%e: o assess patientBs l*ng condition for pre8operation assessment

R$AM$N

1- ilateral tonsillectomy .it, 'A(S) *nder +eneral Anast,esia-

DISCUSSION

onsillitis is an inflammation of t,e tonsils most commonly ca*sed &y %iral or &acterial

infection- Symptoms of tonsillitis incl*de sore t,roat and fe%er-


6/8

,ese stones ca*se a symptom of a f*ll t,roat or a t,roat t,at ,as somet,ing ca*g,t in t,e &ac2-

A fo*l &reat, t,at is c,aracteri5ed &y t,e smell of rotten eggs @&eca*se of t,e s*lf*r is also a

symptom of t,is condition- )t,er symptoms t,at can &e ca*sed &y tonsillitis t,at are not

normally associated .it, it incl*de snoring and dist*r&ed sleep patterns- ,ese conditions

de%elop as t,e tonsils enlarge and &egin to o&str*ct ot,er areas of t,e t,roat- A personCs %oice is

generally affected &y t,is type of illness and c,anges in t,e tone of %oice a person normally ,as-


7/8

s.elling- Ice cream/ fro5en yog*rt and ot,er dairy prod*cts are not recommended

&eca*se t,ey lea%e a film in t,e mo*t, t,at is diffic*lt to s.allo.- S,er&etandpopsicles/

on t,e ot,er ,and/ are recommended- Additionally/ Sl*s,iesare partic*larly ,elpf*l for

sore t,roats/ especially .,en s*gar8free-

(ain follo.ing t,e proced*re is significant and may incl*de a ,ospital stay-EReco%ery

can ta2e from 10 *p to 0 days/ d*ring .,ic, narcoticanalgesicsare typically prescri&ed-

(atients are enco*raged to maintain diet of li*id and %ery soft foods for se%eral days

follo.ing s*rgery- Ro*g, text*red/ acidic or spicy foods may &e irritating and s,o*ld &e

a%oided- (roper ,ydration is %ery important d*ring t,is time/ since de,ydration can

increase t,roat pain/ leading to a %icio*s cycleof poor fl*id inta2e-3E4E

At some point/ most commonly #G11 days after t,e s*rgery @&*t occasionally as long as

t.o .ee2s @14 days after/ &leeding can occ*r .,en sca&s&egin slo*g,ing off from t,e

s*rgical sites- ,e o%erall ris2 of &leeding is approximately 1HGH ,ig,er in ad*lts-=E

Approximately 3H of ad*lt patients de%elop significant &leeding at t,is time- ,e

&leeding mig,t nat*rally stop *ic2ly or else mild inter%ention @e-g-/ gargling cold .ater

co*ld &e needed @&*t as2 t,e doctor &efore gargling &eca*se it mig,t &r*ise t,e area of

t,e s2in t,at ,as &een ca*teri5ed- )t,er.ise/ a s*rgeon m*st repair t,e &leeding

immediately &y ca*teri5ation/ .,ic, presents all t,e ris2s associated .it, emergency

s*rgery @primarily t,e administration of anest,esia partic*larly on a patient .,osestomac, may not &e empty-

'a*tery8assisted palatal stiffening operation @'A(S) is a proced*re .,ere t,e s*rgeon *ses

electroca*tery e*ipment to remo%e part of t,e soft palate and *%*la- It &*rns t,e uvulaca*sing

fi&rosis and conse*ent stiffening of t,e *%*la t,*s increase t,e arc, of palate and s*&se*ently

increase t,e air.ay to red*ce snoring- ,ere are no long8term efficacy data a%aila&le at present-6E

According to a st*dy/ its s,ort8term effecti%eness is rated as ,ig, at FH and effecti%eness .it,in

1 mont,s is a%erage at ##H-#E
http://en.wikipedia.org/wiki/Frozen_yogurthttp://en.wikipedia.org/wiki/Dairy_producthttp://en.wikipedia.org/wiki/Sorbet#American_terminologyhttp://en.wikipedia.org/wiki/Popsiclehttp://en.wikipedia.org/wiki/Slush_(beverage)http://en.wikipedia.org/wiki/Tonsillectomy#cite_note-Pediatric_ENT-6http://en.wikipedia.org/wiki/Narcotichttp://en.wikipedia.org/wiki/Analgesichttp://en.wikipedia.org/wiki/Dehydrationhttp://en.wikipedia.org/wiki/Vicious_cyclehttp://en.wikipedia.org/wiki/Tonsillectomy#cite_note-medical-surgical_nursing-7http://en.wikipedia.org/wiki/Tonsillectomy#cite_note-8http://en.wikipedia.org/wiki/Scabhttp://en.wikipedia.org/wiki/Tonsillectomy#cite_note-9http://en.wikipedia.org/wiki/Cauterizationhttp://en.wikipedia.org/wiki/Anesthesiahttp://en.wikipedia.org/wiki/Frozen_yogurthttp://en.wikipedia.org/wiki/Dairy_producthttp://en.wikipedia.org/wiki/Sorbet#American_terminologyhttp://en.wikipedia.org/wiki/Popsiclehttp://en.wikipedia.org/wiki/Slush_(beverage)http://en.wikipedia.org/wiki/Tonsillectomy#cite_note-Pediatric_ENT-6http://en.wikipedia.org/wiki/Narcotichttp://en.wikipedia.org/wiki/Analgesichttp://en.wikipedia.org/wiki/Dehydrationhttp://en.wikipedia.org/wiki/Vicious_cyclehttp://en.wikipedia.org/wiki/Tonsillectomy#cite_note-medical-surgical_nursing-7http://en.wikipedia.org/wiki/Tonsillectomy#cite_note-8http://en.wikipedia.org/wiki/Scabhttp://en.wikipedia.org/wiki/Tonsillectomy#cite_note-9http://en.wikipedia.org/wiki/Cauterizationhttp://en.wikipedia.org/wiki/Anesthesia


8/8

REFERENCES

1- McNeill RA-/ RA @1 *ne 1F60- JA istory of onsillectomy: .o Millenia of ra*ma/

Kmorr,age and 'ontro%ersyJ-Ulser Medical JournalF @1: =FG63- (MID04#64#-

(M'3!433!

- +ra,am/ o,n M-L +lenis - Scadding/ (eter D- *ll @00!- Pediatric ENT- Springer-

pp- 136- ISN3=406FF30F

3- im&y/ ar&ara *,nL Nancy $llen Smit, @006). Introductory medical-surgical

nursing. 9ippincott

Documents

Casewriteup Ent 110911092915 Phpapp01