Pamantasan ng Cabuayo College of Nursing

Case Presentation Acute Tonsillopharyngitis

Presented by: Damasco, Chammy L. Presented to: Mrs. Milagros Mendoza Clinical Instructor, Ward-CMC

Case Abstract

Prior to admission, patient XD, a 23 yrs old female was experience fever, pain in the throat with body weakness. she went to the hospital because of the pain and the experience of 3 days constant fever. She initially diagnosed of suspected dengue fever, but then the doctor found out that her final diagnosis was acute tonsillopharyngitis.

Review of Anatomy and Psysiology

Tonsil and Pharynx

Pathophysiology

Patient Assessment Data Base

Health Perception - Health Management Pattern

Present Health Status

Patient XD stated the she experienced pain, body weakness and fever in three days and poor appetite a few days before the admission. On Last Jan. 05,2011, she decided to be confined at Calamba Medical Center. The doctor told her that she needs to be admitted to the hospital for further observation because of her illness was still unclear. The doctor initially diagnosed her as expected dengue fever because of evidence by having sing and symptoms just like three days fever. After her being assessed, the doctor found out that her tonsils are swelling and presence of pain characterized of presence of infection. They conducted a laboratory procedure to check her current status, the result of increase WBC and low lymphocytes was found and read as caused by bacterial infection. The doctor finally diagnosed the patient XD having an acute tonsillopharyngitis.

Past Health Status

Patient XD stated that its her first time being confined at any hospitals ever since as she remember, common colds, fever and illness are being self medicated, except for the immunization she have before, she completely immunize.

Family Health History

patient XD stated that her family was prone to heart problems and most of them died with that cause.

Nutrition Metabolic Pattern

Before the admission, patient XD had poor appetie and can't tolerate to eat because of swelling throat. Now after three days of confinement, I witness the patient is no longer in pain and the burden of eating is gone, now having her normal food intake

Elimination Pattern

Patient XD voids 3-19 times a day because of the increase of fluid intake. Her urine is light yellow in color. Her bowel elimination pattern is not daily.

Sleeping Pattern

During confinement, Patient XD stated that she cannot sleep soundly because she is not so comfortable inside the hospital.

Cognitive Perception Pattern

Patient XD has no difficulty in hearing or in vision

Physical Assessment

Laboratory Data

Drug Study

Nursing Care Plan

Prognosis
My patient got recovered from the hospital and now back at her usual daily activities