a case study on tonsillitis

this is a case study on tonsillitis , this details about the diagnosis, management, treatment, patient counselling & pharmacist interventions , regarding medication etc , and also describes in detail about all aspects of tonsillitis .
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1. CASE STUDY BASED ON DISEASE { TONSILLITIS } PREPARED BY MARTIN SHAJI Pharm D

2. Patient name –Ms. x O P no. –145028 Admission date- 30-2- 19 Age-25 Sex-M Department- General medicine PATIENT DEMOGRAPHY

3. 1. Physical examination: patient conscious and coherent Vital signs: Temperature ( o F ): 100 Pulse rate (/min): 76beats Blood Pressure (mm of Hg ):120/80mm of Hg 2. Systems Examination: CVS: S1, S2 + RS: Clear GENERAL EXAMINATIONS

4. SUBJECTIVE EVALUATION A 25 years old male patient was consulted with the complaints of fever for few days at frequent intervals along with throat pain, sore throat, difficulty swallowing, and cough with sputum . Inflamed tonsils are noticed . OBJECTIVE EVALUATION On Examination, the patient was conscious & coherent . ASSESSMENT : Based on subjective & objective evaluation the physician confirmed it as Tonsillitis. SOAP NOTES

5. CONFIRMATORY DIAGNOSIS TONSILITIS

6. From the examination the patient was noticed with inflamed tonsils hence, he is advised to use salt gargle thrice a day , also avoiding cool food items . Considering the severe inflammation the patient should provided with penicillin's, or antibiotics . Past medication history of the patient has shown that penicillin sensitivity in the subject , hence Azithromycin and Metronidazole has to provided. Along with paracetamol [ analgesic & antipyretic] , here the patient having elevated temperature. PLANNING

7. Sl.No . Drug Indication ROA Frequency and dose. Brand Name Generic Name 1. ZITHROMAX   AZITHROMYCIN ANTIBIOTIC ORAL BID 250 MG/ 7 DAYS 2.   T. PCT PARACETAMOL ANALGESIC & ANTIPYRETIC ORAL OD 500MG/ 7 DAYS 3. RANTAC RANITIDINE H2 - BLOCKER ORAL BID 25 MG/ 7 DAYS 4. T. B ACTIVE B COMPLEX VITAMIN SUPPLEMENT ORAL OD / 7 DAYS DRUG CHART

8. REGARDING MEDICATION AZITHROMYCIN ; 250 mg BID is used orally for 7 days, Azithromycin is an antibiotic used for the treatment of a number of bacterial infections. Paracetamol 650mg BID is used as an anti-pyretic. It act as a pain killer and also as temp lower. Given for 7 days RanitidinE 25mg BD is used as an anti-ulcerative drug which reduce stomach irritation , donot take more than two weeks given for 7 days . B. COMPLEX The B vitamins are eight water-soluble vitamins that play important roles in cell metabolism. Supplements containing all eight are generally referred to as a vitamin B complex . Suggested for 7 days , so as to ensure the patients health and improve the resistivity to the infection.

9. PHARMACIST INTERVENTIONS The prescription was rational. No DDI or ADRs were found.

10. DISCUSSION Tonsillitis  is inflammation of the tonsils, two oval-shaped pads of tissue at the back of the throat — one tonsil on each side. Signs and symptoms of  tonsillitis  include swollen tonsils, sore throat, difficulty swallowing and tender lymph nodes on the sides of the neck.

11. PATIENT COUNSELING- Instructions for patient Easing the pain of a sore throat:  Suck on a throat lozenge, hard candy or popsicle; take acetaminophen (Tylenol or ibuprofen (Advil); gargle with warm salt water (1/4 tsp. salt per glass of water); drink plenty of liquids; and eat soft, bland foods. Throat sprays ( Chloraseptic ) can also provide pain relief • Gargle with warm salt water • Drink warm tea • Suck on popsicles