Acute Amigdalitis

UNEVERSITATEA DE STAT DE MEDICINA SI FARMACIE

“ NICOLAE TESTEMITANU “

DIN REPUBLICA Moldova

Department of infection in adults

 Medical Report:

Department of infection

Represented by :Amor Hisham

Group:1040

CHISINAU 2015

 Medical Report:

Department of infection

General Data :

First Name :Ana

Family Name : Crijanovschi

Age : 21

Sex: female .

Date of hospitalization : 2.09.2015

Definitive Diagnosis:

Acute amigdalitis

Clinical symptom:

1.Fever 40 last time

2. headache

3. coughing,swelling,chills

4. red swollen tunsils with pus

History of the present disease :

In 30-8-2015 she feel bad ,In 2-09-2015 she came to the hospital with fever 40 and suffers pain from the throat (inflammation of the tonsils)

History of past disease :

This is the first time that she came to the hospital.

General biographical information :

Birth place : ( chisinau )

Status : single

Normal physical and mental development

No family hereditary diseases .

The patient doesn't suffer from any type of allergies.

Harmful habits : no smoking no alcohol .

Objective examination

General state : Good.

Consciousness : Clear.

Posture of patient : Active.

Constitution : Normosthenic.

Normal facial expressions.

enlargements in the neck.

Pail skin colour .

Normal elasticity , and humidity.

Normal hair growth.

Normal subcutaneous fatty tissue .

No signs of peripheral edema.

Palpation of the lymph nodes : normal dimensions , and no pain during the palpation.

Normal muscles and bones structure, absence of inflammation signs in the joints.

Extremities : absence of any abnormalities.

Pulse: 72\min

Blood pressure:118\78

Capillaries:3 sec

.

Respiratory System

Complains :

No complains .

Inspections :

Symmetrical right and left sides..

Clavicles and the shoulder blades are at the same level.

Supraclavicular fossa equal on both sides .

Palpation :

Normal thorax elasticity .

Normal chest size and shape.

Warm, dry skin.

No tender spots.

Symmetrical chest expansion.

Percussion :

Dullness indicates consolidation .

Resonance sound .

Normal vibration.

Auscultation :

Normal vesicular breathing all over the lungs area .

Normal trachea-bronchial breathing.

No pathological signs.

.

Cardiovascular System

Complains :

Nu complain

Inspection of the heart region :

No pathological phenomenon ( swollen arteries , pronounced pulsation , turgescent jugular veins , .. ).

Palpation :

Apex beat present in the fifth intercostal space , with the area of 1.5-2 cm and a moderate height and power.

No enlargement of the right ventricle.

RV impulse , Epigastric pulsation , Jugular pulsation , thrills are absent.

No pathological signs.

Percussion :

Normal size , position , and shape of the heart .

Normal length of the vascular bundle.

Normal heart borders.

Auscultation :

Every thing is normal nu pathologic sound.

Digestive System

Complains :

Complains: no complains

Inspection :

Normal symmetric form and volume of the abdomen.

Normal colour of the abdomen.

Nu signs of caput medusa was observed.

No presence of surgical scars or other skin abnormalities.

Auscultation :

No pathological signs during auscultation .

Palpation :

No pathological signs appear during superficial and deep palpation of the abdomen.

Liver :

Inspections : no evidence of pulsation in the right hypochondrial space, no evidence of prominent vessels, no enlargement of the liver .

Palpation :

No pain during palpation (no hardening , no consolidation ).

Percussion :

No enlargement of the liver borders.

Gall-bladder :

Palpation :

No pain during palpation (no hardening , no consolidation ).

Percussion :

No pain during percussion.

pancreas :

Palpation :

no enlargement of the panceas .

Urinary System

Complains :

Nu complain

Inspection : ( Lumbar region )

No swelling regions was observed.

Normal skin colour.

No signs of Edema was observed.

Palpation : ( Kidney palpation)

The inferior pole of the right and left kidneys was palpated .

Endocrine System

Complains :

No complains related to endocrine system.

Inspection :

No swelling regions was observed.

Normal skin colour.

No signs of Edema was observed.

Palpation :

Thyroid gland is enlarged , not hardening, not mobile , sensitivity in the area of thyroid gland, the isthmus of the thyroid gland is not enlarged .

Auscultation :

No pathological signs during auscultation (no bruits, no low pith humps – that may indicate goier)

Collecting date :

After taking in consideration all the information about the patient its have seen

That he has HAV infection and we confirm it by clinical investigation :

Clinical investigation :

Result :

After the investigation we supposed that the patient has acute amigdalitis but before confirm the diagnosis we should diffierntiate it with other disease ,and her we make a list with diffierntial diagnosis as writem below:

Diffierntial diagnosis

Infectious mononucleosis(glandular fever)

Herpes simplex virus

Epiglottitis

Behcet's disease

Acute leukaemia

Difinitiva diagnosis:

Acute amigdalitis(candida albicans)…

Treatment:

: ceftriaxone 1 g two time daily

Clemastin 1 T two time daily

Paracetamol 500 mg for temperature >38,5'c