Faculty of Medicine and Health Sciences, UTAR

Score sheet for CASE Write-Up

OTORHINOLARYNGOLOGY
Year 4

Student Name : Chin Wing Yuen

ID No. 15 UMB 00831 Year : 2019

Name of lecturer: Dr. Ahmed Waleed Khalid

Marks allocation for Case Write-up

Chief complaints /5 Investigations (indications, /10

results & interpretation)

History (chronologically clear /20 Management & progress of /10

with relevant positive & the patient in the ward
negative findings)

Physical Examination (relevant /20 Discussion on final diagnosis /10

positive & negative findings)

Critical discussion of the case /10

(learning issues, evidence-
Summary of the case (clear & /5 based management,
concise) prognosis, communication,
ethical issues and
professionalism)

Discussion of diagnosis / /10

differential diagnosis based on Total score /100
clinical findings
 PATIENT IDENTIFICATION

Patient’s Initial : Nor Shamsiah

R/N : AM 00680430

Age : 25 years old

Gender : Female

Ethnic group : Malay

Date of admission to Hospital (ED / Ward) : 12/07/2019

Date of discharge from Hospital : 15/07/2019

Date of clerking : 12/07/2019 & 15/07/2019

Source of History : Miss N (Hospital Ampang, Ward 5B, Bed 12) and another patient in Bed
9
 CLINICAL FINDINGS & DISCUSSION

Chief Complaint(s):

Miss N, a 25 years old obese Malay lady is presenting with progressive shortness of breath
for 1 day.

History of Presenting Illness:

Miss N was apparently well until 4 days ago when she experienced an acute onset of fever
and sore throat. She felt warm and was experiencing chills and rigor, but she did not manage to
document her temperature at home. Her fever was continuous and was not periodic or intermittent.
Her sore throat was associated with odynophagia and she was unable to eat solid food as per usual.
However, she was still able to drink water and fluids. She thought that it was a mild sore throat
and did not seek any medical attention.

Her symptoms progressively worsened until she developed an acute onset of shortness of
breath one day ago. She had noisy breathing which was not relieved by any method. She also
noticed that she had to clear her throat more frequently, and the occasional mucus produced were
clear in consistency. Forceful hawking will cause her sputum to have streaks of blood within the
expectorated mucus. She also experienced 2 episodes of vomiting, which was mainly clear fluids
with no blood or bile-stained contents. Besides that, she also noticed that her voice changed and
became muffled. At this point, her fever and odynophagia had worsened and she was experiencing
lethargy and had progressed to dysphagia, causing her to become unable to tolerate any food or
liquid. She rated the pain 8 out of 10 on the numeric pain rating scale.

In view of her worsening symptoms, she took 2 tablets of Paracetamol in the morning, but
the symptoms did not resolve and kept worsening. Hence, she went to the emergency department
of Hospital Ampang to seek for medical attention.

Throughout the episode, she did not experience any cough, rhinorrhea, watery eyes,
earache, ear discharge, hearing impairment, headache, chest pain or hemoptysis. Besides that, this
is her first time experiencing such severe odynophagia and shortness of breath, and she did not
experience any recurrent sore throat in the past. There were also no history of loss of weight or
loss of appetite before the incident. She also did not undergo any dental surgeries or procedures
lately.

In addition to her current presenting symptoms, she also experienced snoring for 5 years
duration when she sleeps, and is associated with sudden waking up from sleep and gasping for air.
She also said that other people who had been present beside her while she is sleeping mentioned
that she had loud irregular snoring with a long pause in between, which in this case is supported
by another patient in the ward during the 3 nights she spent with her in the ward. She also had
excessive daytime somnolence for the past few years. The conditions affecting her was getting
worse and is affecting her daily activities for the past one year.

Systemic Review:

Systems Findings

General review Her mood is gloomy and she is lethargic.

Central Nervous She does not have any loss of consciousness, visual disturbances,
System headaches, weakness of limbs or any balance and coordination
dysfunction.

Cardiovascular She denies experiencing any orthopnea. No claudication or reduced

system effort tolerance was experienced by the patient.

Gastrointestinal She did not experience any abdominal pain or distention, no diarrhea or
system constipation, no haematemesis, no blood in stools, and no change in
colour or consistency of stools.

Genitourinary Urine output was normal as usual. No dysuria, nocturia hematuria or

system urethral discharge was experienced. Her last menstrual period was 3
weeks ago. Her menarche started at the age of 12 with normal cycle and
regular flow.
 Endocrine She did not experience any polyphagia and polydipsia. No heat / cold
system intolerance, and no changes in sweating was experienced.

Musculoskeletal There was no complaints of joint pain, stiffness, history of falls or

system swelling in upper or lower limbs.

Others No bleeding or bruising noted at any areas. No skin rashes was

experienced by the patient as well.

Past Medical History:

Patient is healthy and does not suffer from any diseases. She does not have underlying
hypertension, diabetes mellitus, ischaemic heart disease, bronchial asthma, or any previous history
of stroke. She also does not suffer from repeated attacks of tonsillitis or have any recurrent oral
ulcers.

Past Surgical History:

Miss N have not undergone any operation before in the past.

Family History:

Miss N’s father passed away at 41 years old due to ischaemic heart disease, in which he
also suffered from hypertension. Fortunately, other immediate family members of Miss N have no
known medical illness (NKMI), and they do not have a history of malignancy. Miss N is not
married.

Medication & Allergy History:

Miss N does not take any drug on a regular basis, and is not on any prescribed drugs by the
doctor. She is also not consuming any traditional medications and have no known drug or food
allergy.

Dietary History:

For her diet history, her diet contains plenty of carbohydrates and fatty foods. She likes
taking sweet carbonated drinks as well as fast food (McDonald’s, KFC etc.). She can also eat up
to 2 servings of rice sometimes. She also eats a lot of snacks like potato chips and cookies.
Social History:

She is an ex-smoker. She started smoking when she was 22 years old but she managed to
completely stop smoking at the age of 25 years old. She used to smoke approximately 2 packets
of cigarettes per day, and this totals up to approximately 6 pack year. She does not consume any
alcoholic beverages and she has not been involved in any drug abuse before. She has been working
as a supervisor in a supermarket for the past 3 years and is financially stable. She lives in Pandan
Indah and she is living alone.
 PHYSICAL EXAMINATION

Anthropometric Measurement:

Height: 1.54 m

Weight: 159.6 kg

BMI: 67.3 kg / m2

Interpretation: Patient is in Class III obesity (severe obesity).

Vital Signs (at ED):

Components Value Reference Range Interpretation

Blood Pressure (mmHg) 156 / 83 90 / 60 - 140 / 90 Hypertensive

Pulse Rate (beats per minute) 103 60 - 100 Tachycardia

Respiratory Rate (breaths per 17 12 - 20 Normal

minute)

Tympanic Temperature (˚C) 36.8 36.8 - 37.5 Normal

SpO2 (% under room air) 99 94 - 100 Normal

Dextrose Stick Test (mmol / L) 4.9 4.4 - 7.8 Normal

Glasgow Coma Scale 15 15 Normal

Interpretation: Miss N has underlying tachycardia and hypertension. Her tachycardia could be
due to her anxiety and difficulty in breathing, causing her to have a slightly borderline elevated
heart rate. However, her hypertension should be investigated or at least monitored, as she is young
(25 years old) and young hypertension can have serious comorbidities in the future.
General Examination:

On general inspection, patient is alert, conscious, and well oriented to time, place and
person. She is sitting up comfortably on the bed and does not seem to be in any respiratory distress
or in pain. She is not on any oxygen therapy and no nasal prongs or high flow mask is seen near
her bed. She had a branula inserted at the dorsum of her left hand. She does not appear toxic-
looking and is not agitated.

Findings of Organ / System Examination:

Oral Cavity Examination:

On examination of the mouth, the cutaneous part of the lips along with the vermilion border
were dry with cracked surfaces, indicating that the patient might be dehydrated (most probably
due to reduced fluid intake). The mucosal surface was moist. No swellings, vesicles, ulcers, crusts,
scars, clefts or angular stomatitis were seen.

After instructed to open her mouth, no trismus was seen. Upon examination of the oral
cavity, the colour of the buccal mucosa was hyperaemic, but it is moist. There are no ulceration,
vesicles, bullae, leukoplakia, erythroplakia, pigmentation, atrophic changes in mucosa, swelling
or any masses seen. Both openings of the parotid ducts are seen opposite to the upper second molar
tooth. It is normal with no swelling or redness seen in the overlying mucosa.

Examination of the gums and teeth revealed pink and normal looking gums. No ulceration,
hyperplasia, abnormal masses of dental caries were seen. The oral hygiene was good. Examination
of the hard palate revealed a normal arched palate with no cleft palate. oronasal fistula, vesicles,
ulcers or mass seen.

Examination of the tongue revealed a tongue with normal size and shape. It is pink with
absence of fissures, ulcers, masses or whitish patch. Elevation of the tongue revealed normal
opening of the submandibular duct on the side of the frenulum. No scars, ulcers or swelling were
seen as well. No halitosis were appreciated. The floor of the mouth was not raised. Palpation of
the floor of the mouth was refused by the patient.

Oropharynx Examination:
 On examination, the tonsils are enlarged bilaterally, with the right tonsil larger than the left
one (asymmetrical enlargement). The right tonsil is Grade IV whereas the left tonsil is
approximately grade II. There are streaks of yellowish-whitish layer like cheesy material covering
the right tonsil. The tonsils appear erythematous and swollen. No ulcers, masses, membranes,
blood clots, active bleeding or bulging of the peritonsillar region was seen. Uniform congestion of
the pillars, tonsils and pharyngeal mucosa was seen, No ulceration of growth was seen at the tonsil.
Lateral pharyngeal wall was unable to be visualized due to the obstruction by the enlarged tonsils.
Palpation of tonsils with wooden tongue depressor was rejected by patient as she was in severe
pain.

On examination of the soft palate, the soft palate was injected and slightly edematous.
However, the uvula is central with no deviation to either side. On examination of the posterior
pharyngeal wall, no lymphoid nodules could be seen due to the obstruction of view. No purulent
discharge, hypertrophy of lateral pharyngeal bands or crusting seen. Base of the tongue and the
valleculae were not able to be visualized. Indirect laryngoscopy was not performed as the patient
refused and the doctor scheduled a nasopharyngolaryngoscopy for her.

Ear Examination:

There are no swelling, scars or fistula seen at the mastoid region. Palpation of the mastoid
region revealed no tenderness. On examination of the external ear, the shape and position of the
ears are normal. There are no apparent redness, swelling, vesicles, scars, ulceration or neoplasm
at the pinna of the ear. The movement of the pinna was painless and there was no raise in
temperature felt.

On examination of the external auditory canal without a speculum, the meatus is wide with
a little ear was found in both ears. No discharge, polyp or swelling of the wall is seen. With a
speculum, the rest of the external auditory canal was normal with a little ear wax and no discharge,
polyp, granulation tissue, masses or foreign body.

On examination of the tympanic membrane, bilateral ears show pearly white tympanic
membranes which is semi transparent. The tympanic membrane is not retracted nor bulging, and
the surface of the tympanic membrane is smooth without any evidence of perforation. The cone of
light can be seen at the anterior inferior quadrant and all other quadrants have normal structure.
No foreign body or inflammation can be identified in both ears.

Rinne test was positive on both ears, and Weber test showed equal intensity of the sound
perceived by the patient. No further hearing assessment such as absolute bone conduction test was
done as the patient has perfectly normal hearing and there was no indication to perform additional
tests to assess the hearing ability.

On examination of the eyes, there are no nystagmus seen, and since the patient did not
complain of any vertigo or dizziness, further tests on vertigo and dizziness such as head shaking
nystagmus test, positional testing and fistula test was not performed.

Facial Nerve Examination:

On general examination, the patient does not have any asymmetry of the face. The
nasolabial fold is seen clearly with no drooping at the angle of the mouth. Upon raising her
eyebrows, normal wrinkles can be seen in the forehead on both sides. She is also able to close her
eyes fully and forcefully, and is able to resist forceful opening. She is also able to smile and show
her teeth with equal elevation of the angle of the lip, and she is able to puff her cheeks and hold
the air when her cheeks are being pressed upon. She is also able to clench her teeth and raise her
platysma. Since her facial nerve assessment was normal, the topodiagnostic tests for facial nerve
is not performed as there are no indications.
Nose Examination:

On examination of the nose, the overlying skin does not have any inflammation, scars,
sinuses, swelling or any growth seen. There are also no osteocartilaginous framework deformities
like crooked or twisted nose. No polyps of the nose were seen from the external acoustic meatus,
and palpation of the nose revealed a normal temperature, no tenderness, fluctuation or crepitation
felt. Cold Spatula Test was normal on both sides of the nostrils.

Tilting up the nose revealed a normal nasal septum which is not deviated and does not have
any nasal septal haematoma or epistaxis seen. The vestibules are also normal with no furuncle,
crusting or any tumours.

Anterior Rhinoscopy was performed with the help of a Thudicum nasal speculum. On
examination, the nasal passage is normal with no apparent narrowing or widening. The septum is
not deviated and does not have any spur, ulcer, perforation, swelling or growth seen. The inferior
turbinates are normal with no hypertrophy, atrophy or hyperaemia seen. The floor of the nose is
also normal with no defect, swelling or neoplasm seen. No discharge or bleeding was seen as well.
The cold spatula test was normal for both nostrils.

Neck Examination:

On examination of the neck, the neck appears short and wide with multiple skin folds. No
scars or swelling were visible. Lymph node examination revealed a solitary enlarged mass located
at the right neck. It is most likely lymph node enlargement. It is at level III middle jugular node,
which is in between the hyoid bone and the lower border of cricoid cartilage. The size is
approximately 2 cm x 2 cm with soft consistency and it is tender to touch. It is not fixed to the
underlying structures and is normal in temperature. Lymph node examination at other levels as
well as preauricular, postauricular and occipital regions revealed non-palpable lymph nodes.

For her trachea, there was no tracheal deviation and her larynx moves with deglutition.
Laryngeal crepitus is also present. No apparent swelling of the neck was seen as well.
Respiratory System:

Inspection - There was no clubbing and no peripheral cyanosis of her fingers. No nicotine stains
were found. The chest is symmetrical, with no deformities or scars found and the chest moves with
respiration. Her respiratory rate was 20 breaths per minute upon examination, and no central or
peripheral cyanosis was observed.

Palpation - No tracheal deviation was felt. The chest was symmetrical and chest expansion was
normal on all 3 levels of the chest. No chest tenderness was elicited on both sides of the chest.
Cricosternal distance was normal.

Percussion - The upper, middle and lower zones of the lungs demonstrated normal resonance. The
anterior, posterior and lateral sides demonstrated similar resonance.

Auscultation - Normal vesicular breath sounds were heard at all lung zones. No prolonged
expiratory phase or any added sounds (rhonci, rales, crackles) were heard. Breath sounds were
reduced bilaterally but is very likely to be due to the thick chest wall due to her obesity.

Cardiovascular System:

Inspection - There was no flushing of the face, no xanthelasma, corneal arcus, or any xanthoma.
No splinter hemorrhages was found on the nail bed, no Janeway lesions or Osler’s nodes were
found on the hand. The chest is symmetrical with no presence of any scars, deformities, or any
chest wall abnormalities.

Palpation - Pulses were felt on both sides on the lower limbs, good volume, regular rhythm and a
pulse rate of approximately 94 beats per minute. Jugular venous pressure (JVP) was unable to be
clearly seen due to the thick neck folds. The apex beat was unable to be felt due to the thick chest
wall. No sacrum or pitting edema at the legs was felt.

Auscultation - Basal crepitations were unable to be appreciated. Third and fourth heart sounds
were not heard. S1 was heard loudest at mitral area whereas S2 was heard loudest at aortic area. A
regular rhythm was heard, with no murmurs or any additional sounds. No carotid bruits were heard.

Abdominal System:
Inspection - The abdomen appears distended and moves with respiration. The umbilicus is
inverted and located at the middle. There is no scratch marks, flank fullness, dilated veins,
abdominal striae, visible mass nor any visible peristalsis.

Palpation - Upon light and deep palpation, the abdomen demonstrated no rigidity, guarding,
masses or any tenderness over the 9 regions of the abdomen. On deep palpation, the liver and
spleen was not palpable. The kidneys were unable to be balloted due to the skin folds.

Percussion - Liver and splenic dullness were unable to be appreciated due to the thick skin folds.
No shifting dullness or fluid thrills were appreciated.

Auscultation - Normal bowel sounds were heard. No bruits were heard.

Central Nervous System:

Cranial Nerves

Cranial Nerves Findings

I (Olfactory) ● Unable to carry out due to lack of equipment such as coffee beans.

II (Optic) ● Visual field was normal for both eyes.

III (Oculomotor), ● Normal pupillary constriction upon direct and consensual light
IV (Trochlear), reflexes.
VI (Abducens) ● Eyeballs movements were normal on the horizontal and vertical
plane.

V (Trigeminal) ● Sensory test was done by using cotton wool and the sensations were
equal on both sides of the face for ophthalmic, maxillary and
mandibular divisions.
● There was no wasting of muscles of mastication and the bulk of the
muscle was normal. Upon applying resistance on the jaw, the
patient was able to resist the resistance and no deviation of the jaw
was noted.
 ● Corneal reflexes were elicited on both sides of the eyes.
● Jaw jerk was elicited as well.

XI (Accessory) ● Able to resist resistance upon applying resistance on the shoulders

on both sides.
● Sternocleidomastoid muscle bulk was normal on both sides.
● Able to resist resistance upon applying it on both left and right sides
of the jaw.

Motor Component
On inspection of both upper and lower limbs, there were no surgical scars, no muscle
wasting, no involuntary movements, no fasciculation and no tremor. The tone was normal for both
sides on both upper and lower limbs. The power of upper and lower limb was normal (5/5). All
reflexes were elicited. Clonus test was negative and Babinski sign showed downward movement
of toes on both sides.

Sensory Component
Pain sensations were felt on C5, C6, C7, C8, and T1 areas on both upper limbs and were
equal on both sides. Other than that, pain sensations were felt on L1, L2, L3, L4, L5, S1 and S2
areas and were equal on both sides. Upon conducting proprioception test, patient was able to sense
the position of his thumbs and big toe on both sides indicating intact proprioception. Therefore,
both spinothalamic and dorsal column tracts were intact.

Cerebellar test
Cerebellar tests were normal. Patient was able to perform accurately for finger-to-nose,
rapid palm movement and heel-to-shin tests.

Gait
Gait is normal.

Musculoskeletal Examination:
Inspection
On inspection of both upper and lower limbs, there were no swelling, no surgical scars, no changes
on the skin colours, no deformity and were symmetry when compared to both sides of the limbs.

Palpation
There was no tenderness claimed by the patient while palpating both upper and lower limbs.

Movements (active and passive)

Both active and passive movements were able to be done and the range of movements are normal.
No pain was complained and observed during the movements.
 SUMMARY OF THE CASE

Miss N, A 25 years old obese Malay lady is was apparently well until 4 days ago when she
experienced acute onset of fever and sore throat. She also experienced odynophagia when eating
solid food, but was still able to tolerate liquids. Her symptoms worsened until she develop
odynophagia to fluid and solid as well as acute onset of shortness of breath. It was associated with
hawking and lethargy as well as voice changes.

Besides that, she also experienced restless sleep with waking, gasping episodes as well as
loud snoring with apneic episodes. There is also excessive daytime sleepiness which affected her
quality of life, and the symptoms are also progressively worsening. She was an ex-smoker with 6
pack year.

Physical examination revealed that she is in Class III Obesity, and she is hypertensive as
well as tachycardic upon presentation at the Emergency Department. The right tonsil is Grade IV
whereas the left tonsil is Grade II in size. There are also yellowish cheesy material on the right
toneil, and they appear edematous and erythematous bilaterally. Uniform congestion of the pillars,
pharyngeal mucosa and the soft palate was seen. A unilateral right sided level III lymph node was
enlarged and tender with soft consistency. Ear and nose examination revealed no positive findings
and facial nerve examination was normal.
 PROVISIONAL DIAGNOSIS

Acute Follicular Tonsillitis With Possible Obstructive Sleep Apnea (OSA)

First of all, the patient’s symptoms had a rapid onset and progression, plus she did not have
repeated episodes of sore throat or fever for the past few years, indicating that the problem is very
likely to be an acute rather than a chronic problem. Next, her fever and sore throat started first
above all other symptoms. This usually indicates that the pathology is more likely to originate
from the pharynx. Next, she developed odynophagia and subsequently dysphagia, with the
inability to tolerate solid food first followed by liquids. This indicates that there is an obstructive
lesion at the passage from the oropharynx to the oesophagus. Next, she developed shortness of
breath, which might be due to the obstruction of the airway due to the tonsils. Her symptoms also
worsened as the days progressed.

Physical examination also revealed bilateral enlargement and inflammation of tonsils

(Grade II - left, Grade IV - right) with streaks of cheesy material over the right tonsil. Hence, the
diagnosis of follicular tonsillitis was established. There is also a unilateral anterior cervical lymph
node enlargement which is tender upon palpation. Despite the patient’s age which does not fit into
the common age group which usually presents with tonsillitis, it is still possible for her to have an
acute severe tonsillitis.

Secondly, the reason for suspecting obstructive sleep apnea is clear. She has most of the
symptoms of obstructive sleep apnea, including restless sleep with waking, gasping, loud irregular
snoring, and excessive daytime sleepiness. On examination, she also has hypertension which was
previously unknown. Systemic hypertension is one of the sequelaes of chronic obstructive sleep
apnea as the brain increases the sympathetic activity of the body due to hypoxia, causing secondary
systemic hypertension. She also has one of the major risk factors for developing OSA, which is
obesity. She was also a previous smoker, which adds on to her risk of developing OSA.
 DIFFERENTIAL DIAGNOSIS

1. Peritonsillar or parapharyngeal abscess

Peritonsillar abscess as well as parapharyngeal abscess usually follows acute tonsillitis,

which is something that physicians should remember as it is one of the complications of tonsillitis,
and management is different from that of simple acute tonsillitis.

Peritonsillar abscess usually affects adults, and they are generally unilateral. Miss N has a
larger tonsil on one side compared to another, and this raises the suspicion of peritonsillar abscess
in my mind. Next, they usually present as high fever, chills and rigors, general malaise, headache,
nausea and vomiting, which our patient experienced part of the symptoms mentioned. Peritonsillar
abscess also causes severe odynophagia in which it is so marked that the patient cannot even
swallow her own saliva which dribbles from the angle of her mouth. Although this feature is not
present in Miss N, she does seem to be progressing towards that as she is already experiencing
severe dehydration as evidenced by her dry cracked lips. She also had muffled voice as well as
severe pain in the throat.

However, the evidence against peritonsillar abscess include halitosis, ipsilateral earache as
well as trismus. However, the absence of these symptoms does not mean that it is not peritonsillar
abscess, as the patient might be progressing towards developing those symptoms. The uvula
however does not appear swollen or deviated upon examination, and bulging of soft palate is also
not visible.

For parapharyngeal abscess, it can also be due to acute infection of the tonsils, which is an
extension of the tonsillar infection to the neck space. However, the triad of symptoms includes
prolapse of tonsils and tonsillar fossa, trismus and external swelling behind the angle of the jaw.
Miss N only has prolapse of tonsils, and with the absence of trismus and external swelling at angle
of jaw, it is less likely, but the possibility of this condition developing is still possible. Palpation
was rejected by the patient, if not the presence of pus flowing out from the tonsils as well as feeling
of collection of fluid at the peritonsillar region will be able to rule out these diagnoses.

2. Ludwig’s angina
 Ludwig’s angina is commonly a mixed infection involving aerobes and anaerobes. Alpha-
haemolytic Streptococci, Staphylococci and bacteroides groups are common. It presents with
marked difficulty in swallowing initially (odynophagia), and structures in the floor of the mouth
are swollen when the infection spreads to the submaxillary space. This is consistent with the history
of the patient, who the chief complaint is shortness of breath. The tongue could also only be
depressed with a significant amount of force, due to the swollen submandibular region.

However, the points against the diagnosis of Ludwig’s angina is that the patient’s
submandibular region does not appear swollen, and the tongue does not appear enlarged. The
patient also did not have any dental procedures done recently or any damage or trauma to the teeth
and gums. No cellulitis of the overlying tissues were seen as well. Most importantly, there are no
signs of trismus seen.

3. Central Sleep Apnea

Central sleep apnea is a very important differential diagnosis of obstructive sleep apnea. It
is characterized by a lack of drive to breathe during sleep, resulting in insufficient or absent
ventilation and compromised gas exchange. Hypoventilation worsens during non-REM sleep and
further during REM sleep, resulting in marked hypercapnia with accompanying hypoxemia.
Typical symptoms may be similar to patients with OSA, including morning headaches and daytime
hypersomnolence, making it difficult to be distinguished clinically. However, patients with central
sleep apnea might also have obstructive sleep apnea, making it very difficult to separate the disease
into clear entity. Hence, further investigations must be done to differentiate between the 2 diseases.
 INVESTIGATIONS, RESULTS AND INTERPRETATIONS

1. Full Blood Count

a. Indications
i. To detect the presence of leukocytosis which can be raised due to
infection.
ii. To detect reactive thrombocytosis which might be present in an acute
infection.
iii. To detect presence of polycythaemia secondary to obstructive sleep apnea.
b. Result

Components Value Reference Range Interpretation

Red Blood Cell (x 10⁶ / µL) 5.26 3.76 - 5.70 Normal

Hemoglobin (g / dL) 12.5 12.0 - 18.0 Normal

Hematocrit (%) 40.5 33.5% - 52.0% Normal

Mean Cell Volume (MCV) (fL) 77.0 80.0 - 100.0 Low

Mean Cell Hemoglobin (MCH) (pg) 23.8 26.0 - 32.0 Low

Mean Cell Hemoglobin Concentration 30.9 31.0 - 35.0 Low

(MCHC) (g / dL)

Platelet Count (K / µL) 441 150 - 350 Increased

Red Cell Distribution Width (RDW- 13.7 11.6 - 14.0 Normal

CV) (%)

White Blood Cell Count (K / µL) 13.3 4.0 - 9.0 Increased

Nucleated Red Blood Cells (%) 0.0 0.0 - 2.0 Normal

c. Interpretation: Patient has leukocytosis as well as thrombocytosis, and it is most likely due
to the presence of acute infection into the tonsils. The slightly low mean cell volume, mean
cell haemoglobin and mean cell haemoglobin concentration is most likely due to
physiological variance, as the haemoglobin and red blood cells are within normal range.
 However, I would repeat the test to ensure that the patient does not have any underlying
pathology and monitor the white cell count.

2. White Blood Cell Differential Count

a. Indications
i. As the total white cell count is increased, this test is required to determine
which white cell line is increased and thus, identify the type of infection.
b. Result

Components Value Reference Range Interpretation

Absolute neutrophil (K/uL) 10.4 3.9 - 7.1 High

Absolute lymphocyte (K/uL) 1.8 1.8 - 4.8 Normal

Absolute monocyte (K/uL) 1.1 0.4 - 1.1 Normal

Absolute eosinophil (K/uL) 0.1 0.0 - 0.8 Normal

Absolute basophil (K/uL) 0.0 0.0 - 0.1 Normal

Percentage of neutrophil (%) 77.7 30.0 - 65.0 High

Percentage of lymphocyte (%) 13.2 40.0 - 70.0 Low

Percentage of monocyte (%) 8.1 2.0 - 10.0 Normal

Percentage of eosinophil (%) 0.8 1.0 - 4.0 Low

Percentage of basophil (%) 0.2 0.5 - 1.0 Low

c. Interpretation: The patient has neutrophilia, and the percentage of neutrophils is also
significantly higher than the rest of the cell types. This indicates that the infection is very
likely to be bacterial in origin.
3. Renal Profile
a. Indication
i. To screen for any major electrolyte concentration abnormalities
ii. To see whether any acute kidney injury develops due to dehydration.
b. Result

Components Value Reference Range Interpretation

Urea (mmol/L) 3.40 2.50 - 8.07 Normal

Sodium (mmol/L) 135 136 - 146 Low

Potassium (mmol/L) 3.8 3.4 - 4.5 Normal

Chloride (mmol/L) 101 98 - 107 Normal

Creatinine (umol/L) 69 44 - 80 Normal

c. Interpretation: All of the parameters are within normal range except for sodium, which is
borderline low. This could be due to the presence of dehydration of the patient, causing
the drop in sodium levels as the kidneys attempts to remove it. However, it is still within
acceptable range and requires only monitoring, and no need for medical intervention.

4. Bedside Flexible Nasopharyngolaryngoscope

a. Indications:
i. As the posterior and lateral pharyngeal wall cannot be entirely visualized,
as well as the patient rejected palpation of the tonsils, it is required to screen
for any complications which might have developed secondary to the
tonsillitis.
ii. To look for any other levels of obstructive sleep apnea besides the tongue,
which will be useful for the management of the patient in the future.
 b. Results:
i. Nasopharynx examination revealed normal nasal septum, inferior and
middle turbinates as well as floor of the nose. Fossa of Rosenmuller as well
as opening to Eustachian tube was normal bilaterally. Moderate adenoid
hypertrophy was seen with erythema, covered with thick mucoid discharge
and slough. Adenoiditis was diagnosed.
ii. Oropharynx endoscopy revealed bilateral tonsillar enlargement, with the
right tonsil larger than the left tonsil. The tonsils appear inflamed, and
exudates were seen over the right tonsil. No medialization of lateral
pharyngeal wall was seen, and no bulging of the posterior pharyngeal wall
was seen as well.
iii. Hypopharynx endoscopy revealed normal arytenoid, anterior epiglottic fold
as well as epiglottis. Bilateral pyriform fossa was normal, vocal cord was
fully mobile, and the subglottic area as well as post cricoid region is normal.
The airway is patent with no signs of obstruction or excessive secretions.
No inflammation was seen over the epiglottic, glottic and subglottic region.

5. Throat Swab Culture and Sensitivity

a. Indications:
i. To identify the causative organism of tonsillitis.
ii. To identify the susceptibility of the pathogen towards the antibiotics and
select the best one.
b. Results: Culture shows multiple colonies on the agar plate. Microscopic examination
revealed that it is Group A Streptococcus. No resistance to any antibiotics was seen.
c. Interpretation: Causative organism is Group A Streptococcus, and the current antibiotic
regime can be continued.
 MANAGEMENT AND PROGRESS OF PATIENT IN THE WARD

First of all, this patient requires hospitalization, as she had already developed shortness of
breath and is experiencing severe odynophagia with difficulty in tolerating solid food or even
liquids. She is also experiencing tachycardia and hypertension, and should be admitted into the
ward for monitoring.

In the emergency department, in view of her dehydration status, the physicians set up an
IV line at her right dorsum, and they transfused her with one pint of normal saline over 1 hour
duration. Next, over the next 24 hours, they gave her 5 pints of normal saline over 24 hours in
view of her inability to tolerate oral fluids and food. They also planned and carried out the above
blood investigations in order to assess the severity of her disease. They then quickly referred her
to the ENT specialist on call and the specialist decided that she should be warded for further
management.

Next, they prescribed her with Paracetamol tablets 1 tablet four times per day to control
her pain. She was also started on IV Augmentin 1.2 g stat in order to fight off the infection in her
tonsils. Difflam gargle 1.5 mLs 3 times per day was prescribed as well to soothe the throat and to
reduce the bacterial load. Before commencing, they also managed to get a throat swab for culture
and sensitivity.

In view of her weight, they also stressed to measure BMI as well as neck circumference
once in the ward. They also ordered a tonsillitis diet (die with soft food and easy to swallow) and
monitor her vital signs every 4 hourly. Subsequently in 2nd day, the added celebrex tablet 200 mg
stat for her twice per day in order to reduce the infection in her tonsils. They also planned to refer
this patient to internal medicine department in view of her high blood pressure despite well
controlled pain for further investigations.

After the infection has settled, they plan to perform a sleep study in order to diagnose her
having obstructive sleep apnea. Next, they also referred her to a dietician in order for her to learn
the right way to control her diet and to have a balanced diet. As the days progressed, she got better
and her symptoms resolved, and she was subsequently seen by the medical department and was
discharged with medications and follow up.
 Before being discharged, she was briefed by the ENT physician that she will be required
to reduce her weight in order to improve her symptoms of sleep apnea. She was given an
appointment for admission into Ward 5B on 21st of August for sleep study, and she was given an
appointment in the ENT outpatient clinic in 1 months’ time. She was discharged with Augmentin
tablet 625 mg twice per day for a week, along with Difflam gargle and Paracetamol tablets.
 DISCUSSION ON FINAL DIAGNOSIS

To differentiate between viral and bacterial causes, the Modified Centor Score is used in
order to determine whether this patient requires antibiotics or not. It is a set of criteria used to
estimate the probability that pharyngitis is caused by Group A Streptococcus. The table below
summarizes the points and the diagnostic approach.

Criteria Points awarded

No cough 1 point

Tender anterior cervical adenopathy 1 point

Fever 1 point

Tonsillar exudates or swelling 1 point

Age

3 - 14 years 1 point

15 - 44 years 0 point

> 44 years -1 point

Approach:

Score ≤ 1 No further diagnostic testing ot antibiotic

treatment is indicated

Score 2 or 3 Rapid antigen detection testing (RADT)

and/or throat culture is indicated

Score ≥ 4 Empiric Antibiotics

Based on the patient’s clinical findings and history, she had a total score of 4 (indicated by
the red wording). This indicates that she no longer requires a throat culture, and the physicians can
straight away start her on empirical antibiotics, as the pharyngitis and tonsillitis were most likely
caused by Group A Streptococcus.
 With the findings of adenoid hypertrophy upon flexible endoscopy, the final diagnosis
would be as follows:

Acute Follicular Streptococcal Tonsillitis With Adenoiditis with Possible Obstructive Sleep
Apnea (OSA)

For acute tonsillitis, we should always look out for possible development of complications.
The complications of tonsillitis are as below:

1. Chronic tonsillitis with recurrent acute attacks. Hence, it is important to ask the patient to
complete her antibiotics to avoid incomplete resolution of acute infection.
2. Peritonsillar and parapharyngeal abscess. If the fever does not subside or the symptoms
persists despite medical treatment, then the physicians should start suspecting the presence
of abscess as the antibiotics are not able to reach the site.
3. Acute Otitis media. Recurrent tonsillitis may cause acute otitis media. Hence, the patient
is asked to return to clinic if there are any signs of otitis media such as discharging ear or
sudden reduced hearing.
4. Rheumatic fever and Acute glomerulonephritis. These are rare but are associated with
Group A Beta Hemolytic Streptococci, which is the causative agent in this patient. Hence,
she should be told about the possibility of developing such conditions, although these
conditions are rare these days.
5. Subacute Bacterial Endocarditis. In her case, it is unlikely that she has valvular heart
disease, but we are unable to be sure because she did not perform any ECG. However, the
usual causative agent would be Streptococcus Viridans, which is not the causative agent in
this patient.
 CRITICAL DISCUSSION OF CASE

First of all, for her management, there are some key points that I wish to highlight. In the
emergency department, with her shortness of breath as well as obese, the physicians should at least
perform an ECG as a baseline investigation to screen for underlying cardiac abnormalities. Besides
that, lipid profile should also be ordered as she is morbidly obese and a LDL and triglycerides
level should be determined so that she can be managed accordingly. An arterial blood gas should
also be done in order to see the oxygenation status of her blood.

For her management, they prescribed her with oral paracetamol tablets. For me, I think that
she should be prescribed with IV drugs whenever possible, as she is having severe odynophagia
and asking her to swallow a Paracetamol tablet not once, but 4 times per day is a bit too much to
ask. Instead, IV Ibuprofen could be given to manage the pain instead.

Finally, they made the right choice by referring her to medical department. A young 25
year old with no known medical illness with a BMI of 67 is very dangerous as she is at high risk
of many complications, and she might have an underlying disease which could have caused her to
have obesity, such as hypothyroidism or Polycystic Ovarian Syndrome. The underlying cause
should be find out in order to help her obstructive sleep apnea to improve. Physical activity and
healthy diet were advised as well in order to help reduce her weight, which will eventually improve
her symptoms of obstructive sleep apnea.

For her prognosis, the prognosis of acute tonsillitis without complications are very good
and she should recover without suffering from any major complications. Her airway obstruction
was also almost resolved by the time of discharge, and her right tonsil reduced from Grade IV to
Grade III for the right tonsil. She should probably make a full recovery in a few weeks' time.
 DISCUSSION ON PATIENT SAFETY AND PROFESSIONALISM

In terms of professionalism, before taking any history or performing any physical

examination, I introduced myself as a Year 4 medical student from Universiti Tunku Abdul
Rahman. I explained the purpose of the history taking and physical examination to her, and
explained to her that all the information which I have obtained will be kept private and confidential
and used only for academic purposes. After gaining verbal consent from the patient, I offered my
patient a chaperone to accompany her when conducting the history taking and physical
examination.

During the entire session of clerking, my chaperone helped me to write down important
findings as I pay full attention to my patient. This is to ensure her that I am paying full attention to
what she is saying and not just merely writing down what she say without even listening.

Before performing physical examination, I closed the curtain and performed alcohol hand
rub. This is crucial as I do not wish to introduce any pathogens which might cause an infection to
the patient. After ensuring privacy to the patient, I explained to her that the flow and contents of
the entire physical examination before performing. This is to ensure that the patient knows what
to expect and is both mentally and physically prepared for it.

In terms of ethics and patient safety, non-maleficence is crucial in my case as I certainly

do not wish to do any harm to the patient. Hence, with this is mind, patient’s safety is my utmost
priority and I take extra precautions not to be careless and cause any worsening of the patient’s
condition.

There was no major communication issues faced while clerking Miss N as we both can
converse in Bahasa Malaysia. There was no language barrier between us as I understand and am
able to speak the language. I avoided using medical terms that may confuse the patient and spoke
in a clear audible tone. I made sure to summarize what I have asked her and ask her to correct me
if I am wrong. At the end, I also apologized to her if I have offended her in any way and caused
pain to the patient during physical examination.