FACULTY OF MEDICINE

OTORHINOLARYNGOLOGY POSTING
CASE WRITE-UP
PATIENT DETAILS

NAME : MISS X
AGE : 20
GENDER : FEMALE
RACE : MALAY
OCCUPATION : UNEMPLOYEED
MARITAL STATUS : SINGLE
ADDRESS : KB KELANTAN

CHIEF COMPLAINT
Persistent sore throat associated with fever for 4 years
HISTORY OF PRESENT ILLNESS
- Patient mentioned that the sore throat prolongs for 2-3 days duration and resolves with
antibiotic and painkillers.
- The frequency of the sore throat is almost every month for the past 4 years and the last
episode was on November 2021.
- Patient mentioned that this sore throat is aggravated with swallowing foods and drinks
and the pain will be more severe at night.
- Patient claimed that she will be having shortness of breath on and off at night.
- Patient mentioned that there is small amount of whitish sputum discharge upon coughing.
- Patient claimed that her appetite is normal, there is no significant weight lost, no bleeding
tenancy and no headache.
- Patient mentioned that she snores sometimes at night but no episode of apnoeic.
- Patient claimed that she will be having tiredness on and off during day time.

PAST MEDICAL HISTORY

- Denied any past medical or surgery history, and claimed that patient doesn’t have any
history of hospital admission

DRUG HISTORY
- Antibiotics
- Painkillers

ALLERGY HISTORY
- No significant history of allergies
FAMILY HISTORY
- There’s no history of persistent sore throat in the family
- There’s no history of malignancy in the family
- There’s no other significant family history
SOCIAL HISTORY
- Patient has a father, mother and 7 more siblings.
- She’s the youngest and unemployed
- no history of smoking or consumption of alcohol.
- has cats & carpets at home.
SUMMARY
- A 20-year-old young lady with not know medical illness presented with persistent sore
throat associated with fever for 4 years. Pain is aggravated with swallowing foods and
drinks and resolves with antibiotic and painkillers.

PHYSICAL EXAMINATION FINDINGS

- On examination, the patient is alert, conscious, not tachypnoeic, not s talk in full
sentences, had warm peripheries and capillary refill time less than 2 seconds.
- No trismus
- Denture is healthy and no loose teeth
- Swollen tonsils can be seen. Right tonsil with 3rd grade while the left tonsil with 2nd grade.
- No debris
- No white or yellow patches and hot injected
- No lymph node palpable
- No neck nodes palpable

IMPRESSION:
1. Tonsillar swelling (Tonsilitis)

PLAN:
1. Tonsillectomy
2. Follow up