PATIENTS BIODATA

Name

: Mr Hamidin

Age

: 30 years old

Sex

: Male

Race

: Malay

Date of presentation : 19/06/2016

PRESENTING COMPLAINT
Electively admitted for bilateral tonsillectomy

HISTORY OF PRESENTING COMPLAINT

The patient came to the clinic last year due to chronic snoring problem for the past 4 years. It
was worsening progressively with increased in weight gain. It was also associated with shortness
of breath which causes him to wake up in the middle of the night. During the day, he feels
lethargic and sleepy. Due to this, his daily work was also affected.
Patient also had recurrent sore throat for the past 1 years with attack as frequent as once monthly
with or without fever. The sore throat episodes were usually preceded by upper respiratory tract
infection. It was also associated with cough.
Otherwise, there was no pain, altered taste, dryness, trismus, dysphagia, odynophagia and ear
ache. There was no voice change, no loss of appetite and loss of weight.

PAST MEDICAL AND PAST SURGICAL HISTORY

Unremarkable

DRUGS AND ALLERGIES

He is allergic to seafood where he will develop ithciness all over the skin. Otherwise, he has no
other known allergies.

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

: 86 beats/min, regular and good volume

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

For pre-operation assessment

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

1. Conservative treatment : Antimicrobial therapy

2. Surgery : Bilateral tonsillectomy under General Anasthesia

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:

high temperature (fever) over 38C (100.4F)

coughing

headache

earache

feeling sick

feeling tired

swollen, painful lymph glands in your neck

loss of voice or changes to your voice

Treatments for Tonsillitis

Treatment for tonsillitis will depend in part on the cause. To determine the cause, your doctor
may perform a rapid strep test or throat swab culture. Both tests involve gently swabbing the
back of the throat close to the tonsils with a cotton swab. A lab test can detect a bacterial
infection. A viral infection will not show on the test, but may be assumed if the test for bacteria is
negative. In some cases, the physical findings are convincing enough to diagnose a probable
bacterial infection. In these cases, antibiotics may be prescribed without performing a rapid strep
test
If tests reveal bacteria, treatment will consist of antibiotics to cure the infection. Antibiotics may
be given as a single shot or taken 10 days by mouth. Although symptoms will likely improve
within two or three days after starting the antibiotic, it's important to take all of the
medication your doctor prescribes to make sure the bacteria are gone. Some people need to take
a second course of antibiotics to cure the infection.
If the tonsillitis is caused by a virus, antibiotics won't work and your body will fight off the
infection on its own. In the meantime, there are things you can do to feel better, regardless of the
cause. They include:

Get enough rest

Drink warm or very cold fluids to ease throat pain

Eat smooth foods, such as flavored gelatins, ice cream, or applesauce

Use a cool-mist vaporizer or humidifier in your room

Gargle with warm salt water

Suck on lozenges containing benzocaine or other anesthetics

Take over-the-counter pain relievers such as acetaminophen or ibuprofen.

When Tonsillectomy Is Needed

Tonsils are an important part of the immune system throughout life, so it is best to avoid
removing them. However, if tonsillitis is recurrent or persistent, or if enlarged tonsils cause upper
airway obstruction or difficulty eating, surgical removal of the tonsils, called tonsillectomy, may
be necessary. Most tonsillectomies involve using a conventional scalpel to remove the tonsils;
however there are many alternatives to this traditional method. Increasingly doctors are using
techniques such as lasers, radio waves, ultrasonic energy, or electrocautery to cut, burn, or
evaporate away enlarged tonsils.