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Name
: Mr Hamidin
Age
: 30 years old
Sex
: Male
Race
: Malay
FAMILY HISTORY
Patients mother has hypertension while his father is a diabetic mellitus patient. Both of them are
under medication. The patient has 3 siblings and all of them are healthy. There is no one in the
family has same problem as the patient. Otherwise, there were no other chronic medical
illnesses.
SOCIAL HISTORY
Mr. Hamidin is currently single and work as a technician. His total monthly income are
approximately RM2,300. He lives with his friend in a single storey house in Parit Jawa. He is a
smoker of 9 cigarretes per day for the past 10 years. He does not consume alcohol.
PHYSICAL EXAMINATION
GENERAL EXAMINATION
Patient looked obese but generally he was alert and comfortable, not pale looking or jaundice.
Weight: 105 kg
Height: 1.7 m
BMI: 36.33
Vital Signs:
Pulse Rate
Respiratory rate
: 20 breaths/min, regular
Blood Pressure
: 132/70 mmHg
OTORHINOLARYNGOLOGICAL SYSTEM
Oral Cavity
Oral cavity is well hydrated. Mouth opening was good. There was no halitosis. Dentition
was good, no missing teeth and bledding gums. No tongue atrophy or deviation. Hard
palate appeared normal. There was no ulcers or masses seen in the oral cavity.
Oropharnyx
There were bilateral tonsils enlargement. Uvula was slightly erythematous. There was no
ulcers, swelling or any other masses seen.
Ear
The pinna and external auditory meatus were normal bilaterally.
The tympanic
membrane was normal and no abnormalities were seen on both sides. Rinnes test was
positive on both sides. Webers test was equal bilaterally.
Nose
There were no scars, sinus, swelling or any deformities seen. On anterior rhinoscopy, the
septum looked normal. No polyps or foreign bodies were seen.
Neck
The neck was in normal attitude. There was no swelling, discoloration, ulcer, or
prominent veins. There was no tenderness, mass, or lymph node enlargement. The trachea
was not deviated. No nodes or masses were palpable. No abnormalities were seen.
OTHER SYSTEMS
The cardiorespiratory examination revealed normal chest with normal vesicular breath sound and
no added rhonchi or crepitation. Apex beat was not dislocated and first and second heart sound
was heard with no murmur. Abdomen was soft and non tender. There was no organomegaly.
SUMMARY
Mr Hamidin, a 30 year old Malay gentlemen presented with history of chronic snoring for 4
years and 1 year history of recurrent tonsillitis electively admitted for bilateral tonsillectomy.
PROVISIONAL DIAGNOSIS
Chronic Tonsillitis causing obstructive sleep apnea
DIFFERENTIAL DIAGNOSIS
-
Lymphoma
Peritonsillar abscess
Pharyngitis
INVESTIGATION
1. Full blood count
Objective:
To check for and infection and Hemoglobin level since he had been
having recurrent tonsillitis
2. Renal profile
Objective: To assess renal function (pre operation assessment)
3. Liver function test
Objective: To assess renal function (pre operation assessment)
4. Chest x-ray
Objective: To assess patients lung condition for pre-operation assessment
MANAGEMENT
DISCUSSION
Tonsillitis is an inflammation of the tonsils most commonly caused by viral or bacterial
infection. Symptoms of tonsillitis include sore throat and fever. While viral tonsillitis must
resolve on its own, tonsillitis caused by bacteria is treatable with antibiotics, which usually
resolves symptoms in two to three days.
Chronic tonsillitis is a persistent infection in the tonsils. Since this infection is repetitive, crypts
or pockets can form in the tonsils where bacteria can store. Frequently, small, foul smelling
stones (tonsilloliths) are found within these crypts that are made of high quantities of sulfur.
These stones cause a symptom of a full throat or a throat that has something caught in the back.
A foul breath that is characterized by the smell of rotten eggs (because of the sulfur) is also a
symptom of this condition. Other symptoms that can be caused by tonsillitis that are not
normally associated with it include snoring and disturbed sleep patterns. These conditions
develop as the tonsils enlarge and begin to obstruct other areas of the throat. A person's voice is
generally affected by this type of illness and changes in the tone of voice a person normally has.
While a person may only become hoarse, it is possible for laryngitis to develop if the throat is
used too much while the tonsils are swollen or inflamed. Other uncommon symptoms that can be
experienced with tonsillitis include vomiting, constipation, a tongue that feels furry or fuzzy,
difficulty opening the mouth, headaches and a feeling of dry or cotton mouth.
Other common symptoms of tonsillitis include:
coughing
headache
earache
feeling sick
feeling tired