CRIMEAN FEDERAL UNIVERSITY ENT- DEPARTMENT

Head of department- Mr.A.V.ZAVADSKIY,PROFESSOR

GUIDED BY-ASST.PROF.-M.A.ZAVALIY(MD)

HISTORY OF PRESENT DISEASE:

PATIENT-MICHAEL MARKOV , AGE 18 YEAR.

CLINICAL DIAGNOSIS:

BASIC DIAGNOSIS- PERITONSILLAR ABSCESS.

COMPLICATIONS: No complication.

By: AMIT K. NAIN

Year: 4th year, Group:407

Date of duration:18.10.2015

CONTENTS:

PASSPORT DATA:

Patients full name: Mr. MICHAEL MARKOVAge: 18 yearsMarital status: UnmarriedOccupation: SOLDIERHome address:TITOVA18,Simferopol, CRIMEA

PATIENTS COMPLAINS:Patient complaints about sore throat specially on left side, difficulty in opening of mouth. The patient feels pain during opening of mouth, due to this he feels difficulty in eating and drinking.

ANAMNESIS MORBI:Two days before the patient felt pain in mouth and he felt problems during eating, that’s why he decided to visit doctor and he complaint that he has pain in the mouth and problems in swallowing.

ANAMNESIS VITAE:There is no any significant history of the patient related with any disease. The patient didn’t said anything about his past. There was no any serious disease. The patient

has no any systematic diseases also. The patient has also no any past related with the adenoids.

GENERAL STATE:The general condition of the patient is satisfactory, all the vital organs are functioning properly. Consciousness is clear, patient answers clearly.Posture is active without any help.Habitus (body build) is asthenic type.Inspection of the skin- skin color, elasticity, humidity, cleanness is clear without any pathology.Lymph nodes- lymph nodes of the head neck are normal without any enlargement.Head inspection- Usual middle position, straight of shoulder, round configuration, proportional facial and cerebral parts, covered with hair, there is no signs of Musset’s and Parkinsonism, Normal facial expression.

SPECIAL STATUSNose- Examination of the external nose:In skin examination there is no any signs of inflammation, no scares, no swelling or neoplasm. In the osteocartilaginous framework examination no any signs of deformity revealed. There is no septal deviation, hump and no depressed bridge.

During pulpapation of the nose there is no any pathological signs like raised temperature, fixity of skin, thickening of soft tissue, tenderness, fluctuation, or crepitation.Examination of the vestibule: In the vestibule there is no any furuncle, no crusting, no dislocation of the caudal end of the septum, and no any tumours like cyst, papilloma, or carcinoma.

Anterior rhinoscopy:Nasal passage is normal without narrowing.Septum is normal without any deviation.Floor of the nose is also normal, there is no signs of cleft palate, fistula, swelling, neoplasm or granulation.Roof of the nose: there is no any sings of acute rhinitis.Lateral wall: the color of the mucosa of the turbinate’s and meatuses are normal without any signs of the inflammation. There is no any pathological mass.

Posterior Rhinoscopy:There is no any choanal polyp or atresia.There is no hypertrophy of posterior end of the inferior turbinates.

There is no any discharge in the middle meatus, so we can say that there is no any infection in the posterior ethmoidal and sphenoidal sinuses.

Functional examination of the nose:Potency test of the nose: Spatula test- Normal (-)Cotton wool test- Normal (-)Sense of smell- normal (essence of rose, clove oil, peppermint, coffee).

Nasopharynx:During anterior and posterior rhinoscopy and pulpation there is no any signs of the following diseases or deviations- Nasal obstruction Postnasal discharge Epistasis Deafness(tubal block) Cranial Nerve Palsies Enlargement of lymph node in the neck.

Examination of the Oropharynx:Tonsills and pillers- Slightly asymmetrical peritonsiler bed due to edema, mucosa of the surrounding tissue is bright red. In the anterior superior point of left tonsillar arch we can see an incision of peritonsillar tissues which is covered with the fibrin. There is no changes in the posterior wall.

There is no any pathology in the following structures-Soft palateBase of the tonguePosterior pharyngeal wall.

Examination of the larynx and laryngopharynx:The patient has no any symptoms or complaints which can indicate regarding larynx and laryngopharynx;No disorders in the voice,There is no respiratory obstruction,There is no cough or expectoration,There is no any symptoms of chronic laryngitis, benign or malignant tumors of the larynx.

No pain in the throat.No any symptoms of the dysphagiaNo mass in the neck (cervical nodes are normal, laryngocele absent)

Examination of the Ear:Physical examination-

1) Pinna and surrounding area- shape, size, and position of the pinna is normal.

2) Examination of the external auditory canal- a) Examination without a speculum- we pull the pinna

upward and backward while the tragus is pulled forwards to open the meatus, there is no any pathology.

b) Examination by the speculum- the size of the meatus is narrow so we select speculum as per the size and see inside the external auditory canal and we can reveal that there is no any pathology.

c) Examination of the tympanic membrane: the tympanic membrane is pearly white in color and semitransparent and it is obliquely located at medial end of the meatus.

The tympanic membrane surface has no any vesicle or bullae( herpes zoster of meningitis bullosa). There is no any perforation in the tympanic membrane.

d) Mobility of the tympanic membrane is normal which is determined by the Siegel’s speculum.

4)_Examination of the middle ear- From the semitransparent tympanic membrane we can just imagine about the condition of the middle ear. There is no ingrowth of the squamous epithelium , which mostly can be seen around the perforation.

5)Examination of the mastoid- swelling, fistula, obliteration of retro auricular groove is absent. The mastoid surface is irregular which shows that it is normal. In case of inflammation smoothness can be observed.

6) Examination of the Eustachian tube- there is no perforation in the tympanic membrane so we cannot examine the anterior part of middle ear where the eustachinan tube can be seen. Pharyngeal opening can be seen by the posterior rhinoscopy.

The functioning of tube can be observed by Valsalva maneuver. In the presence of perforation, air can be felt to escape from the ear when patient tries to blow with mouth and nose close.

LABORATORY ANALYSIS:Blood analysis- Hemoglobin-14.1 normal

- Erythrocytes-4.82*1012 normal- Thrombocytes-266*109 normal- Leukocytes-4.2*109 normal- Color index- 0.98- HTC-46%- ESR:14.5 mm/hr.- Neutrophil- segmented.

Urine Analysis :

Common bilirubin- 10.3 mg/ liter

Direct bilirubin: 3.3 mg/liter

Indirect bilirubin: 7.4 mg/liter

Blood glucose: 3.6 mmol/liter

HIV; negative

Hepatitis viruses; negative

Syphilis; negative

Diphtheria; negative.

Additional examination: X- ray examination of the chest dated 18/10/2015 cx NR8552 . No pathological shadow is visible, and the heart shadow is also normal.

SUSTANTIAN AND DIFFERENTIATION OF THE DIAGNOSIS:

The pain can be observed in other diseases but there is no other signs and symptoms which could suggest the other diseases related to the oral cavity.

TREATMENT AND PREVENTION:Antibiotics are prescribed in which third generation cephalosporin’s are popular. Pain killers paracetamol or ibuprofen can be prescribed. In case of intense pain codeine can also be prescribed.

PROGNOSIS:The patient can be normal after treatment. This is a very common disease which can be treated completely and there is no any post treatment complications. Everything will be normal after treatment.

REFERENCE:Ear Nose and Throat disease – Dr.DhingraOtorhinolaryngology- prof. Y.Mitin and prof. Y.Deyeva.Internet resources.

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