Ppt on ATP

1. Acute
Tonsillopharyngitis
Ghimire, Rupak Raj
PGI
AUFMC

2. Subjective
• 25 years old
• Male
• Single
• Catholic
• Angeles City

3. Dysphagia

4. Subjective
• 2 days PTA –
• (+) dysphagia on solid foods, accompanied by fever (undocumented) and headache, 5/10 pain scale,
non radiating
• No DOB, no dizziness, no vomiting, no abdominal pain, no diarrhea, no flank pain
• Self medicated with Paracetamol 500mg every 4 hours which provide slight relief
• 1 day PTC –
• still with same symptoms, continued self medication with Paracetamol
• FHPTA –
• persistence of symptoms, (+) colds, (+) cough, non-productive, thus prompted consult

5. Family
History
• (-)HPN
• (-)DM
• (-)BA
• (-)PTB
• (-)Allergies
• (-)CA
• No previous hospitalization
• No previous surgeries
Past Medical
History
• (-)HPN
• (-)DM
• (-)CAD
• (-)CVA
• (-)BA
• (-)PTB
• (-)CA

6. Personal social history
• Non smoker
• Non alcoholic beverage drinker
• Denies illicit drug use

7. Review of Systems
 General: No chills, no weight loss, no fever, (+) pallor
 Skin: no rashes, no pruritus
 HEENT:blurring of vision, hearing loss, ear discharge
 Respiratory: No cough, sputum production, hemoptysis, night sweats, shortness of
breath
• Gastrointestinal: Dysphagia, nausea, hematemesis, abdominal pain, hematochezia,
melena.
• Neurologic: No paralysis, memory loss, nervousness, insomnia, vertigo, tremors,
sensorial problems.

8. Objective
• General Survey: Conscious, coherent, ambulatory,
• Vital Signs: BP 110/80, HR 78 bpm, RR 18 cpm, 37.1◦c
• Skin: no jaundice, no pallor
• Eyes: pink palpebral conjunctivae, anicteric sclera
• Ears: No tragal tenderness, no discharge
• Nose: Nasal septum midline, no nasal discharge, turbinates not congested
• Mouth:: moist buccal mucosa, no oral lesions

9. • Throat: hyperemic, hypertrophic and non-exudative tonsils
• Neck: Supple neck, trachea midline, no neck vein engorgement, thyroid not enlarged, non-palpable cervical
lymph nodes
• Respiratory: Symmetrical chest expansion, (-) retractions, (-) crackles (-) wheezes, clear breath sounds
• Cardiovascular: adynamic precordium, apex beat at 5th LICS MCL, no heaves, no lifts, no thrills; no
murmurs
• Gastrointestinal: Flat abdomen, no striae, normoactive bowel sounds, tympanitic, soft abdomen, no direct
and rebound tenderness on all quadrants, no guarding, no mass, no organomegaly
• Extremities: Pulses full & equal, no cyanosis, no edema
• Neurologic: GCS 15, (-) focal neurologic deficits, with 5/5 MMT on all extremities
Objective

10. COMPLETE BLOOD COUNT RESULT NORMAL VALUES
Hematocrit 0.42 0.36-0.45
Hemoglobin 143 130-153 g/L
RBC
MCV
MCH
MCHC
Leukocyte
5.89
84.10
31.6
34.8
15.45
4.6-6.0
80-92.1
27.5-33.2
33.4-35.3
32.30-36.50
4.5-11.00 x 109/L
Neutrophils 0.75 00.18-0.70
Lymphocytes 0.20 0.10-0.48
Monocytes
Eosinophil
0.03
0.01
0.00 - 0.04
0.00-0.03
Platelet 320 150-400x 109/L

11. Assessment
• Acute Tonsillopharyngiti

12. Plan
• Diet: Diet as tolerated
• Avoid spicy food, dry or fried foods, caffeine
• Diagnostics:
• CBC

14. • Therapeutics
• Paracetamol 500mg/tab, 1 tab for T>37.7C
• Co-amoxiclav 500mg/tab 2 times a day for 7 days
• Suggest bactidal gargle

15. Thank you
Have a Good Day 