A 45 year old female with Right tonsillar Hypertrophy with Acute gastritis
A case of 45 year old female with complaints of swelling in B/L Tonsils,Pain and burning sensation in the throat
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This is the case I have been given :-
A 45 year old female who is a power press operator by occupation came with
C/o Swelling of B/L Tonsils since 2 years
C/o Pain and burning sensation in the throat
C/o Difficulty in swallowing since 2 years
C/o Back pain since 6 months which is aggregated on doing work
C/o Excessive day time sleepiness since 6 months
Patient was apparently asymptomatic 10 Years back and then she developed B/L tonsil swelling which were touching each other and got cured but taking medication. Then 2 years back she again developed swelling in bilateral tonsils which were associated with pain and burning sensation in the throat and difficulty in swallowing, which aggravates on eating sweets and sweet items which will be relieved on mouth gargling. 6 months back she developed excessive daytime sleepiness which was uncomfortable and has a H/o waking from sleep due to cough and dryness of tongue. For which she went to ESI hospital where she was diagonised to have chronic tonsillitis for which she used medication
- T. Amoxiclav ,T. Levocet 5 mg ,T.Pan 40mg
After using medication she developed pain in the epigastric region which is burning type.
This pain is relieved on taking medication Pan 40mg. Then she developed back pain for which she went to ESI hospital again where she was prescribed analgesics and pain relieved. After Taking that medication T. Ultracet,T.Calceum,T.Mvt
Past history :-
N/K/C/O DM,TB,HTN,ASTHMA, EPILEPSY, THYROID.
She had Hystrectomy done in 2008 due to fibroid and later she developed burning micturition which relieved on taking more water and medicationmedication
Vitals @ Admission :
Temp: 98.6F
BP:120/70 mmHg
HR:80 bpm
RR: 18 cpm
GRBS: 103 mg/dL
SpO2: 98% on RA
General Examination:
Pt is c/c/c
NoPallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
Thyroid normal
Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: NVBS, BAE+
CNS - NAD
PA - Soft , Tenderness+
Investigations -
Ent referral done on 27/05/2022
Provisional Diagnosis :-
Right tonsillar Hypertrophy with Acute gastritis
Treatment:-
1)Orally Allowed
2)Betadine Gargles U-U-U
3)T.Pan D Po/od 30mins BBF
4) W/F Snoring and presence of any abnormal movements in the sleep
5) Monitor Saturations during Sleep.
SOAP NOTES ICU BED-3, DAY -1
DOA: 27/05/2022
S:
No fresh compliants
O:
BP: 120/70 mmHg
HR:78 bpm
RR: 20 cpm
TEMP: 98.3 F
SPO2:98% on RA
GRBS: 105 mg/dL
General Examination:
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal
Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS:
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs
No meningeal signs
A:
Right Grade II Tonsillar Hypertrophy with Acute gastritis
P:
1)Orally allowed
2)Betadine Gargles U-U-U
3)T.Pan D Po/od/30mins BBF
SOAP NOTES AMC BED-5, DAY -2
DOA: 28/05/2022
S:
No fresh compliants
O:
BP: 120/70 mmHg
HR:78 bpm
RR: 20 cpm
TEMP: 98.3 F
SPO2:98% on RA
GRBS: 105 mg/dL
General Examination:
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal
Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS:
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs
No meningeal signs
A:
Right Grade II Tonsillar Hypertrophy with Acute gastritis
P:
1)Orally allowed
2)Betadine Gargles U-U-U
3)T.Pan D Po/od/30mins BBF
SOAP NOTES General ward , DAY -3
DOA: 29/05/2022
S:
No fresh compliants
O:
BP: 120/70 mmHg
HR:78 bpm
RR: 20 cpm
TEMP: 98.3 F
SPO2:98% on RA
GRBS: 105 mg/dL
General Examination:
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal
Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS:
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs
No meningeal signs
A:
Right Grade II Tonsillar Hypertrophy with Acute gastritis
P:
1)Orally allowed
2)Betadine Gargles U-U-U
3)T.Pan D Po/od/30mins BBF
Discharge Summary
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