Objective : We did this case study for us to enhance our knowledge and to understand more information about tonsilitis,thus

to give an idea how we could give proper nursing care to the clients with this condition.therefore,we could apply them on our future exposure as students of medical assistant.we also did this case study as a part of our requirement in our clinical exposure. At the end of the study, ill be able to: know the anatomy and physiology of the body part ororgan involved; know the disease, its different causes, specific signs andsymptoms, medical managements, and othercomplications; identify different nursing interventions that are applicableto the condition; an apply the acquired knowledge to an actual situation.

Introduction : Im muhammad farhan bin mastuki,group 5 of DMA,student management and science university (MSU) would like to thank to hospital serdang because provide us a best place for our clinical placement.then,to our clinical instructor,mr mohd noor pawanteh for their patience in teaching us and making sure we learn most from our clinical exposure. The purpose of case study is to be familiar with a patient undergo tonsilitis.how it start,what are the causes and what are the sign and symptoms.especially how to prevent,treat and manage the patient by giving medication for treatment.i choose this case study because this is first time i have encountered a case like this in our rotation.

ANATOMY AND PHYSIOLOGY The Tonsils

Definition: Tonsillitis is inflammation of the pharyngeal tonsils. The inflammation usually extends to the adenoid and the lingual tonsils; therefore, the term pharyngitis may be used interchangeably. Pharyngotonsillitis and adenotonsillitis are considered equivalent for the purposes of this article. Lingual tonsillitis refers to isolated inflammation of the lymphoid tissue at the tongue base. Tonsils are part of the bodys lymphatic system. These areorgans which are of importance in the creation of the blood and theyare organs which fulfill important tasks: protection and detoxificationof the body and elimination of matter which should be eliminated. Theyalso act as organs for the regulation of the activity of the entiremucous membrane. There are three groups of tonsils. The pharyngeal tonsils, or adenoids, are located near theinternal opening of the nasal cavity.

The lingual tonsil is a rounded mass of tissue on theposterior surface of the tongue. The palatine tonsils are located on each side of theposterior opening of the oral cavity. They usually are thetonsils that many people are referring to. The work done by the tonsils is similar to that done by the lymphglands. By the formation of new white blood corpuscles and by filteringthe stream of the lymph, the germs of disease, metabolic poisons, andthe foreign bodies are arrested and are made innocuous. Tonsils andglands fulfill the same function, but there is this difference: the tonsilsare not encapsulated in connective tissue. They can expand towardsthroat and mouth and their special formation with deep indentures andclefts makes it possible for the tonsil to get greatly enlarged if necessary. Foreign bodies, body toxins, and germs, which have beencarried into the tonsils by the lymph stream, can therefore beeliminated by way of the mouth, and thus the body is ridded of noxiousmaterials. The lymph circulation is of great importance to our health andthe flow of lymph through the tonsils is one of the most importantdefensive mechanisms of the human body. Good health requires thatthe tonsils should function properly. In adults, the tonsils decrease insize and may eventually disappear. Nature of the Disease

Tonsila are ovoid masses of lymphoid tissue that act as a filteragainst disease organisms. However, they often become a site of infection, a condition known as tonsillitis, and sometimes becomeenlarged. It is most commonly caused by group A beta-hemolyticstreptococcus. According to studies, this microorganism can be presentin certain kinds of foods such as fried foods, flesh foods, pickles, tea,coffee, sugar, white flour, and all products that are made with sugarand white flour. There is no proof that smoking contributes to itsdevelopment but research shows that smoking weakens the immunesystem.Symptoms of tonsillitis include a severe sore throat which maybe experienced as a referred pain to the ears, painful and difficultswallowing, coughing, headache, myalgia, fever, and chills. It ischaracterized by signs of red and swollen tonsils which may have apurulent exudative coating of white patches or pus. Swelling of theeyes, face, and neck may also occur. Tonsillitis may be acute (having presence of white patches) orchronic (persistent infection having no presence of white patches). Inany form, it is more prevalent during
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childhood since tonsil tissuetends to regress with age. It can occasionally become serious. Forexample, infection may spread beyond the tonsil to form an abscess,which is a localized collection of pus. An abscess that forms around aninflamed tonsil is known as a peritonsillar abscess or quinsy. Thisalmost always develops on one side only and usually in adults ratherthan children. Another type of abscess, one that develops mainly inyoung children, is a retropharyngeal (behind the throat) abscess. Thisusually causes high fever and great difficulty in swallowing. The most serious complication of tonsillitis is rheumatic fever,which often is accompanied by rheumatic heart disease. Rheumaticfever develops only if the tonsillitis is due to group A beta-hemolytic streptococcus. It also usually occurs only in children whohave had repeated infections that have not been adequately treatedwith antibiotics.Whether tonsillitis is caused by a viral or bacterial infection,home care strategies can be made to provide comfort and promotebetter recovery. Encourage the person to get plenty of sleep and torest his or her voice. Plenty of water should be given to keep the throatmoist and prevent dehydration. Warm liquids (broth, caffeine-free tea,or warm water with honey) and cold treats (ice pops) can soothe a sorethroat. If the person can gargle, a saltwater gargle of 1 teaspoon of table salt to 8 ounces of warm water can also help soothe a sorethroat. Have the person gargle the solution and then spit it out. It isalso important to avoid irritants. Keeping the home free from cigarettesmoke and cleaning products can help.If tonsillitis is caused by a bacterial infection, the doctor willprescribe a course of antibiotics. Penicillin taken by mouth for 10 days

is the most common antibiotic treatment prescribed for tonsillitis. If theperson is allergic to penicillin, the doctor will prescribe an alternativeantibiotic such as erythromycin. The person must take the full courseof antibiotics as prescribed even if the symptoms go away completely.Failure to take all of the medication as directed may result in theinfection worsening or spreading to other parts of the body.If tonsillitis is caused by a virus, like Epstein-Barr virus or theCoxsackie virus, the length of the illness depends on which virus isinvolved. Usually viral infection is selflimiting; the body fights off theinfection on its own within one week. However, some rare viralinfection resolves for up to two weeks.If detected very early, peritonsillar or retropharyngeal abscessescan sometimes be treated successfully with antibiotics. In
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most cases,however, surgery is required to drain the abscess. Removal of thetonsils, called tonsillectomy or adenoidectomy, is sometimes advised if frequent inflammation poses a threat to health. The lingual tonsilbecomes infected less often than the other tonsils and is more difficultto remove.

Patient particular : Name :nur adina bt abd aziz Age :20 years old Sex :female Address :d-00-04 lotus apartment,taman puchong prima,47100 puchong selangor. Id no : sd 00310821 Nationality :malay Admission : Date :15-2-2012 History taking : Nur adina bt abd aziz,20 years old ladies.student of diploma in cullinary in universiti kuala lumpur and he live in puchong selangor. she reported drinking coffee every morning. shedenies smoking and drinking alcohol. On the night of february 15, 2012, she felt hot and experienced a sore throat. His complaints started with cough and he used to bring out yellow or white sputum.she complained of throat pain. The episodes were always associated with fever which was within the range of38c-39c. He had marked difficulty in swallowing. The past 3 days she also complained of breathing difficulty. she therefore used to wake up frequently at night. His mother (who accompanied him to the clinic) remarked that she used to snore every night and she always slept with her mouth open. she also on many occasion had salivation during sleep.Since the past 4 years it was noted that he used to frequently bite his nails.

Past medical history : she has 2-3 episodes of urticaria in the past at the age of 1 year and 3 years. He however was reported to be asymptomatic since the past 1 year. Past surgical history : This patient has no past surgical history.
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Physical asessment Vital sign : Temperature : 38c (axillary) Pulse rate : 78 bpm Respiration rate : 22 cpm Blood pressure : 110/90 (sitting) Spo2 : 98% Physical examination : During the general examination,patient was alerta nd concious.patient has regular radial pulse,no dullness sound when doing percussion and normal apex beat of the heart. On the respiratory examination,patient also arousable and ablr to breath.no deviation of the tracheal during palpation.no hyper resonance sound on the chest during percussion.no vesicular or bronchial breath sound on the auscultation of the heart.On the abdomen examination,the abdomen is soft and tender. On the specific examination in her throat, Her throat examination showed kissing tonsils with septic foci. Even his cervical glands were palpable. His nose had hypertrophied turbinates. Lymph nodes: multiple enlarged lymph nodes were palpable as follows: > two predominately large (1.3 and 1.2 cm in diameter, respectively) on right supraclavicular area and on the lower portion of right posterior triangle of her neck > multiple small lymph node(less than 5 mm in diameter) in chain along both sides of posterior triangle of the neck could be palpated All nodes were soft, non-tender, movable, and smooth surface. ENT examination revealed surgical scar at philtrum and palate. Enlarged tonsils grade III/IV with hyperemia which extended on anterior tonsillar pillars and soft palate were detected There was no exudative patch. Her pharynx was not injected. Her
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conjunctiva was normal.

Literature review : According to the merck manual of medical information,written by mark h beers,page1144, A physical examination of a young patient with tonsillitis may find: Fever and enlarged inflamed tonsils covered by pus. Group A beta-hemolytic Streptococcus pyogenes (GABHS) can cause tonsillitis (strep throat) associated with the presence of palatal petechiae (tiny hemorrhagic spots, of pinpoint to pinhead size, on the soft palate). Neck nodes may be enlarged. A fine red rash over the body suggests scarlet fever. GABHS pharyngitis usually occurs in children 5-15 years old. Open-mouth breathing and muffled voice resulting from obstructive tonsillar enlargement. The voice change with acute tonsillitis usually is not as severe as that associated with peritonsillar abscess. Tender cervical lymph nodes and neck stiffness (often found in acute tonsillitis). Signs of dehydration (found by examination of skin and mucosa). The possibility of infectious mononucleosis due to EBV in an adolescent or younger child with acute tonsillitis, particularly when cervical, axillary, and/or groin nodes are tender. Severe lethargy, malaise, and low-grade fever accompany acute tonsillitis. A grey membrane covering tonsils that are inflamed from an EBV infection. (This membrane can be removed without bleeding.) Palatal petechiae (pinpoint spots on the soft palate) may also be seen with an EBV infection. Red swollen tonsils that may have small ulcers on their surfaces in individuals with herpes simplex virus (HSV) tonsillitis.

 Unilateral bulging above and to the side of one of the tonsils when peritonsillar abscess exists. A stiff jaw, difficulty opening the mouth, and pain referred to the ear may be present in varying severity. Discussion : Physical examination in acute tonsillitis reveals fever and enlarged inflamed tonsils that may have exudates. Acute bacterial tonsillitis is shown. The tonsils are enlarged and inflamed with exudates. The uvula is midline. Group A beta-hemolytic Streptococcus pyogenes and Epstein-Barr virus (EBV) can cause tonsillitis that may be associated with the presence of palatal petechiae. Group A beta-hemolytic Streptococcus (GABHS) pharyngitis usually occurs in children aged 5-15 years. Open-mouth breathing and voice change (ie, a thicker or deeper voice) result from obstructive tonsillar enlargement.

The voice change with acute tonsillitis is usually not as severe as that associated with peritonsillar abscess (PTA).

In peritonsillar abscess (PTA), the pharyngeal edema and trismus cause a hot potato voice.

Tender cervical lymph nodes and neck stiffness are observed in acute tonsillitis. Examine skin and mucosa for signs of dehydration. Consider infectious mononucleosis (MN) due to EBV in an adolescent or younger child with acute tonsillitis, particularly when tender cervical, axillary, and/or inguinal nodes; splenomegaly; severe lethargy and malaise; and low-grade fever accompany acute tonsillitis. An individual with herpes simplex virus (HSV) pharyngitis presents with red, swollen tonsils that may have aphthous ulcers on their surfaces. Herpetic gingival stomatitis, herpes labialis, and hypopharyngeal and epiglottic lesions may be observed.
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Physical examination of a peritonsillar abscess (PTA) almost always reveals unilateral bulging above and lateral to one of the tonsils. Trismus is always present in varying severity. The abscess rarely is located adjacent to the inferior pole of the tonsil.

Inferior pole peritonsillar abscess (PTA) is a difficult diagnosis to make, and radiologic imaging with a contrast-enhanced CT scan is helpful.

Tender cervical adenopathy and torticollis (neck turned in the cock-robin position) may be present.

Ipsilateral otalgia may be observed.

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Investigation : Ct scan : In her cases of peritonsillar abscess (PTA), CT scanning shows Unusual presentations ( an inferior pole abscess). Initial laboratory investigations: CBC: Hb 9.2 g/dl, Hct 28 %, WBC=5,200/cu.mm (N 80%, L 20%), platelets 131,000/cu.mm Peripheral blood smear for malarial pigment: negative

Literature review :

Tonsillitis and peritonsillar abscess (PTA) are clinical diagnoses. Testing is indicated when GABHS infection is suspected.
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Throat cultures are the criterion standard for detecting GABHS. GABHS is the principal organism for which antibiotic therapy (sensitivity 9095%) is definitely indicated. Growing concerns over bacterial resistance make monitoring acute tonsillitis with throat swabs for culture and sensitivity an important endeavor. Relying only on clinical criteria, such as the presence of exudate, erythema, fever, and lymphadenopathy, is not an accurate method for distinguishing GABHS from viral tonsillitis.

Beta-lactamase resistance of streptococcal species may now be observed in up to a third of community-based streptococcal infections. This resistance is probably due to the presence of copathogens that are beta-lactamaseproducing organisms, such as H influenzae and Moraxella catarrhalis. These organisms are able to degrade the betalactam ring of penicillin and make an otherwise sensitive GABHS act resistant to beta-lactam antibiotics. In one study, erythromycin did not inhibit nearly half of S pyogenes isolates. The limited precision of many throat swabs may reduce the usefulness of these samples.

A rapid antigen detection test (RADT), also known as the rapid streptococcal test, detects the presence of GABHS cell wall carbohydrate from swabbed material and is considered less sensitive than throat cultures; however, the test has specificity of greater than or equal to 95% and produces a result in significantly less time than that
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required for throat cultures. A negative RADT requires that a throat culture be obtained before excluding GABHS infection.
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A culture or RADT is not indicated in most cases following antibiotic therapy for acute GABHS pharyngitis. Routine testing of asymptomatic household contacts is similarly not usually warranted.

A Monospot serum test, CBC count, and serum electrolyte level test may be indicated.

Serum may be examined for antistreptococcal antibodies, including antistreptolysin-O antibodies and antideoxyribonuclease (anti-DNAse) B antibodies. Titers are useful for documenting prior infection in persons diagnosed with acute rheumatic fever, glomerulonephritis, or other complications of GABHS pharyngitis. CT scanning may be used to guide needle aspiration in the following situations:

Draining peritonsillar abscesses (PTAs) after an unsuccessful surgical attempt Draining abscesses that are located in unusual locations and are anticipated to be difficult to reach with standard surgical approaches

Discussion : Throat swab With this simple test, the doctor rubs a sterile swab over the back of your child's throat to get a sample of secretions. The sample will be checked in a lab for streptococcal bacteria. Many clinics are equipped with a lab that can get a test result within a few minutes. However, a second more reliable test is usually sent out to a lab that can return results within 24 to 48 hours. If the rapid, in-clinic test comes back positive, then your child almost certainly has a bacterial infection. If the test comes back negative, then your child likely has a viral infection. Your doctor will wait, however, for the more reliable, out-of-clinic lab test to determine the cause of the infection. Complete blood cell count (CBC) Your doctor may order a CBC with a small sample of your child's blood. The result of this test, which can often be completed in a clinic, produces a count of the different
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types of blood cells. The profile of what's elevated, what's normal or what's below normal can indicate whether an infection is more likely caused by a bacterial or viral agent. A CBC is not often needed to diagnose strep throat. However, if the strep throat lab test is negative, the CBC may be needed to help determine the cause of tonsillitis. Management : Nursing care taking vital sign 4 hourly (temperature,pulse rate,respiration,blood pressure,spo2%)to ensure patient stable. Maintain accurate record of intake & output,noting output less than intake,incresed urine. Skin,mucous membrane,peripheral pulses and capillary refill was asessed. Frequent oral hygiene was performed. Doctor plan for operation,tonsillectomy on 16 feb 2012 to removw the tonsills. Normal diet (soft) cold.

Pre-operative care : Before the sugery,patient was asked to empty the bowel within 12 hours. Patient advised to nill by mouth (nbm) within 12 hours. As usual,the consent dorm has to be signed by the patient or patient;s guardian. Patient has given moral support to reduce fearful or anxiety about having surgery.

Post operative care Patients satbility and level of conciousness are the frirst priority after the surgery. Pain control may be necessary as soon as patient concious. Intravenous line drip was set with 2 pints of normal saline and 2 pints of dextrose.

Literature review : According to the merck manual medical information,written by mark h beers,page 1145,it explained :

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Before surgery,teach the patient to deep breath,explaion the procedure that will be performed before,during,and after surgery to help ease the patient anxiety and help ensure cooperation. Nursing care plan intervention and rationale: 1. Assess for excessive bleeding at back of throat, excessive swallowing, bright red bleeding on expectoration or vomitus. Rationale: indication of potential for hemorrhage. 2. Assess for pain descriptions, edema of throat. Rationale: results from surgical trauma. 3. Monitor vital signs every fifteen minutes initially, then every four hours. Rationale: tachycardia, hypotension indication of hemorrhage. 4. Administer analgesic. Rationale: acts to control pain by interfering with CNS pathways; avoid aspirin medications as these increase bleeding tendency. 5. Provide ice pack to throat every four hours. Rationale: promotes comfort; decreases edema and bleeding by vasoconstriction. 6. Encourage clear liquids such a ice chips, gelatin, ice cream, custard. Rationale: provides adequate fluid intake and foods of smooth consistency for easier swallowing without irritation to throat. 7. Avoid use of straw, coughing, clearing throat, blowing nose, sneezing. Rationale: irritates throat and disturbs clotting process caused by suction or pressure. 8. Inform to avoid citrus juices, hot or spicy foods, raw or rough foods for one to two weeks. Rationale: irritating to throat and difficult to swallow. 9. Inform that ear pain may occur. Rationale: a referred pain is common as nerve pathway are disturbed. 10. Use throat spray, gum or lozenge for throat soreness. Rationale: provides anesthesia to reduce pain. 11. Report bleeding that occurs 5-6 days after surgery. Rationale: delayed bleeding may occur post-operatively as the tough fibrous membrane begins to break away from operative site. 12. Inform that healing is usually completed in three weeks. Rationale: allows for patient to resume normal activities and diet

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Discussion : The objective of the nursing care are to verbalize the patient understanding of the disease process,prognosis,and potential complicaion. Conclusion : The patient,nur adina bt abd aziz has shief complaint of fever and sore throat.he admitted in hospital serdang and diagnosed of having a tonsillitis with peritonsillar abscess.bases on the procedure conducted him like ct scan,fbc,rp,lft,sue to result,surgeon decided for a surgey to remove tonsils which is known as tonsillectomy.the following day i was given chance to visit and assess the patient conditions. Since tonsillitis is presence,A peritonsillar abscess (PTA) is a localized accumulation of pus in the peritonsillar tissues that forms as a result of suppurative tonsillitis. An alternative explanation is that PTA is an abscess formed in a group of salivary glands in the supratonsillar fossa, known as Weber glands. The nidus of accumulation is located between the capsule of the palatine tonsils and the constrictor muscles of the pharynx. The anterior and posterior pillars, torus tubarius (superior), and pyriform sinus (inferior) form the boundaries of this potential peritonsillar space. Because it is composed of loose connective tissue, severe infection of this area may rapidly lead to formation of purulent material. Progressive inflammation and suppuration may extend to directly involve the soft palate, the lateral wall of the pharynx, and, occasionally, the base of the tongue. The infection cause also the white blood cell to increase and the neutrophills due to the elevation of white blood cell.the treatment usually done is tonsillectomy,the remove of tonsils. In order to lower the risk of having this kind of condition each and everyone of us must be concious about of many things which include our health.

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References : Book : Mark h beers,(2003) the merck manual of medical information,second home edition chapter 222.page (1144-1150). A anne ballinger and stephen patchett,clinical medicine 4th edition.page 683. Brook I, Frazier EH, Thompson DH. Aerobic and anaerobic microbiology of peritonsillar abscess. Laryngoscope. Mar 1991;101(3):289-92. Brook I, Foote PA Jr, Slots J. Immune response to anaerobic bacteria in patients with peritonsillar cellulitis and abscess. Acta Otolaryngol. Nov 1996;116(6):88891. Goldstein NA, Hammerschlag MR. Peritonsillar, retropharyngeal, and parapharyngeal abscesses. In: Feigin RD, Cherry JD, Demmler-Harrison GJ, et al eds. Textbook of Pediatric Infectious Diseases. 6th ed. Philadelphia, PA: Saunders; 2009:177. Millar KR, Johnson DW, Drummond D, Kellner JD. Suspected peritonsillar abscess in children. Pediatr Emerg Care. Jul 2007;23(7):431-8. Ehlers Klug T, Rusan M, Fuursted K, Ovesen T. Fusobacterium necrophorum: most prevalent pathogen in peritonsillar abscess in Denmark. Clin Infect Dis. Nov 15 2009;49(10):1467-72. Brodsky L, Sobie SR, Korwin D, Stanievich JF. A clinical prospective study of peritonsillar abscess in children. Laryngoscope. Jul 1988;98(7):780-3.

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