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
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