Michael Markov, an 18-year-old soldier, presented with a sore throat and difficulty opening his mouth. On examination, he was found to have swelling on the left side of his tonsillar bed, indicating a peritonsillar abscess. His general examination and lab tests were otherwise normal. He was diagnosed with a basic peritonsillar abscess without complications. He was prescribed antibiotics and pain medications and given a good prognosis, with an expected full recovery after treatment.

1. CRIMEAN FEDERAL UNIVERSITY
ENT- DEPARTMENT
Head of department-
Mr.A.V.ZAVADSKIY,PROFESSOR
GUIDED BY-ASST.PROF.-M.A.ZAVALIY(MD)
HISTORY OF PRESENT DISEASE:
PATIENT-MICHAELMARKOV, AGE 18 YEAR.
CLINICAL DIAGNOSIS:
BASIC DIAGNOSIS- PERITONSILLAR ABSCESS.
COMPLICATIONS: No complication.
By: AMIT K. NAIN
Year: 4th
year, Group:407
Date of duration:18.10.2015

2. CONTENTS:
PASSPORT DATA:
Patients full name: Mr. MICHAEL MARKOV
Age: 18 years
Marital status: Unmarried
Occupation: SOLDIER
Home address:TITOVA18,Simferopol, CRIMEA
PATIENTS COMPLAINS:
Patient complaintsabout sore throat specially on left side,
difficulty in opening of mouth. The patient feels pain
during opening of mouth, due to this he feels difficulty in
eating and drinking.
ANAMNESIS MORBI:
Two days before the patient felt pain in mouth and he
felt problems during eating, that’s why he decided to
visit doctor and he complaint that he has pain in the
mouth and problems in swallowing.
ANAMNESIS VITAE:
There is no any significant history of the patient related
with any disease. The patient didn’t said anything about
his past. There was no any serious disease.The patient

3. has no any systematic diseases also. The patient has also
no any past related with the adenoids.
GENERAL STATE:
The general condition of the patient is satisfactory, all
the vital organs are functioning properly.
Consciousnessis clear, patient answersclearly.
Posture is active without any help.
Habitus (body build) is asthenic type.
Inspection of the skin- skin color, elasticity, humidity,
cleanness is clear without any pathology.
Lymph nodes- lymph nodes of the head neck are normal
without any enlargement.
Head inspection- Usual middle position, straight of
shoulder, round configuration, proportional facial and
cerebral parts, covered with hair, there is no signs of
Musset’s and Parkinsonism,Normalfacial expression.
SPECIAL STATUS
Nose- Examinationof the external nose:
In skin examinationthere is no any signs of inflammation,
no scares, no swelling or neoplasm. In the
osteocartilaginousframework examinationno any signs of
deformity revealed. There is no septal deviation,hump
and no depressed bridge.

4. During pulpapation ofthe nose there is no any
pathologicalsigns like raised temperature, fixity of skin,
thickening of soft tissue, tenderness, fluctuation,or
crepitation.
Examinationof the vestibule:
In the vestibule there is no any furuncle, no crusting, no
dislocationof the caudalend of the septum, and no any
tumours like cyst, papilloma,or carcinoma.
Anterior rhinoscopy:
Nasal passage is normal without narrowing.
Septum is normal without any deviation.
Floor of the nose is also normal, there is no signs of cleft
palate, fistula, swelling, neoplasm or granulation.
Roof of the nose: there is no any sings of acute rhinitis.
Lateral wall: the color of the mucosa of the turbinate’sand
meatuses are normal without any signs of the
inflammation.There is no any pathologicalmass.
Posterior Rhinoscopy:
There is no any choanalpolyp or atresia.
There is no hypertrophy of posterior end of the inferior
turbinates.

5. There is no any discharge in the middle meatus, so we can
say that there is no any infectionin the posterior
ethmoidal and sphenoidalsinuses.
Functionalexaminationof the nose:
Potency test of the nose: Spatulatest- Normal (-)
Cotton wool test- Normal (-)
Sense of smell- normal (essence of rose, clove oil,
peppermint, coffee).
Nasopharynx:
During anteriorand posterior rhinoscopy and pulpation
there is no any signs of the following diseases or
deviations-
Nasal obstruction
Postnasal discharge
Epistasis
Deafness(tubal block)
CranialNerve Palsies
Enlargement of lymph node in the neck.

6. Examination of the Oropharynx:
Tonsills and pillers- Slightly asymmetrical peritonsiler bed
due to edema, mucosa of the surroundingtissue is bright
red. In the anterior superior point of left tonsillar arch we
can see an incision of peritonsillar tissues which is
covered with the fibrin. There is no changes in the
posterior wall.
There is no any pathology in the following structures-
Soft palate
Base of the tongue
Posterior pharyngealwall.
Examination of the larynx and
laryngopharynx:
The patienthas no any symptoms or complaintswhich can
indicateregarding larynx and laryngopharynx;
No disorders in the voice,
There is no respiratory obstruction,
There is no cough or expectoration,
There is no any symptoms of chronic laryngitis, benign or
malignanttumors of the larynx.

7. No painin the throat.
No any symptoms of the dysphagia
No mass in the neck (cervical nodes are normal,
laryngocele absent)
Examination of the Ear:
Physical examination-
1) Pinna and surrounding area- shape, size, and position
of the pinna is normal.
2) Examinationof the external auditory canal-
a) Examinationwithout a speculum- we pull the pinna
upward and backward while the tragus is pulled
forwards to open the meatus, there is no any
pathology.
b) Examinationby the speculum- the size of the meatus is
narrow so we select speculum as per the size and see
inside the external auditorycanal and we can reveal
that there is no any pathology.
c) Examination of the tympanic membrane: the tympanic
membrane is pearly white in colorand semitransparent
and it is obliquelylocated at medialend of the meatus.
The tympanic membrane surface has no any vesicle or
bullae(herpes zoster of meningitis bullosa).There is no
any perforation in the tympanic membrane.

8. d) Mobilityof the tympanic membrane is normal which
is determined by the Siegel’s speculum.
4)_Examinationof the middleear- From the
semitransparent tympanic membrane we can just
imagine about the conditionof the middle ear. There
is no ingrowth of the squamous epithelium, which
mostly can be seen around the perforation.
5)Examinationof the mastoid- swelling, fistula,
obliterationof retro auricular groove is absent. The
mastoid surface is irregular which shows that it is
normal. In case of inflammationsmoothness can be
observed.
6) Examinationof the Eustachiantube- there is no
perforation in the tympanic membrane so we cannot
examine the anteriorpart of middle ear where the
eustachinantube can be seen. Pharyngeal openingcan
be seen by the posterior rhinoscopy.
The functioningof tube can be observed by Valsalva
maneuver. In the presence of perforation, aircan be felt
to escape from the ear when patient tries to blow with
mouth and nose close.

9. LABORATORY ANALYSIS:
Blood analysis- Hemoglobin-14.1 normal
- Erythrocytes-4.82*1012
normal
- Thrombocytes-266*109
normal
- Leukocytes-4.2*109
normal
- Colorindex- 0.98
- HTC-46%
- ESR:14.5 mm/hr.
- Neutrophil-segmented.
Urine Analysis:
Common bilirubin-10.3 mg/ liter
Direct bilirubin:3.3 mg/liter
Indirect bilirubin:7.4 mg/liter
Blood glucose: 3.6 mmol/liter
HIV; negative
Hepatitisviruses; negative
Syphilis;negative
Diphtheria;negative.
Additional examination:X- ray examinationof the chest dated
18/10/2015 cx NR8552 . No pathologicalshadowis visible, and
the heart shadow is also normal.

10. SUSTANTIAN AND DIFFERENTIATIONOF THE DIAGNOSIS:
The paincan be observed in other diseases but there is no
other signs and symptoms which could suggest the other
diseases related to the oral cavity.
TREATMENT AND PREVENTION:
Antibioticsare prescribed in which third generation
cephalosporin’sare popular. Pain killers paracetamolor
ibuprofen can be prescribed. In case of intense pain codeine
can also be prescribed.
PROGNOSIS:
The patientcan be normal after treatment. This is a very
common disease which can be treated completely and there is
no any post treatment complications.Everything will be normal
after treatment.

11. REFERENCE:
Ear Nose and Throat disease –
Dr.Dhingra
Otorhinolaryngology- prof. Y.Mitin and
prof. Y.Deyeva.
Internet resources.
Student’s signature: