MNM march and statisticsof the surgery done

mnm

1. M&M march DR SHALINI PARAMASWARAN

2. Case A

3. Review in ENT CLINIC on 27/3/24 @ 2.00pm Patient A is a 13 years old Malay boy Wt 78.1kg u/l Allergic Rhinitis Obstructive Tonsillar Hypertrophy With Left Vestibular Wart (AHI 24.3) P/W : Fresh Blood Coming Out From Mouth, Sudden Onset Blood Clot. ~ 1 Cup In Amount. Pain Over Throat. O/W No Headache/Giddiness, No Palpitation, No Sob, No Fever, Tolerating Orally Well No Other Bleeding Tendency No Urtisx

4. Currently day 9 post op Was recently discharged from Ward 4A on 21/3/2024 Electively admitted on 19/3/24 for op on 20/3/2024 Adenotonsillectomy And Excision Of Left Vestibule Wart IOF: Adenoid Mild Enlarged, Bilateral Tonsil Grade Iii Good Plane No Tonsileolith Or Exudates .Left Vestibule Mass, Measuring 0.5x 0.5cm Irregular Surface Firm, Pedunculated-> Excised As A Whole POST OP: Pt Well, Tolerating Soft Diet,no Per Oral Bleeding/Nasal Dischrge,afebrile INTRAORAL : Sloughy Tonsillar Bed, No Clot/Bleeder Seen

5. Discharged on 21/3/2024 T Augmentin 625MG BD 1/52 Difflam Gargle 15mls TDS TPCM 1 Gram QID Cold Saline Gargle 15mls Pre And Post Meals, TCA ENT 2/52 TO RV(4/4/24) AT 9AM

6. Upon review in ENT clinic, patient alert, conscious, pink,not tachypneic. BP 105/87, PR 81, T 37.0, SpO2 98% under RA ARS: no blood clot or active bleeding seen Oral cavity: slough over bilateral tonsillar bed, no blood clot, no active bleeding FBC HB 14.9/TWC 12.9/PLT 563. COAG PT 13/INR 1.19/APTT 38.4 Imp: post tonsillectomy bleeding

7. Plan : Admit 4A NBM with IVD maintenance Iv Augmentin 1.2G TDS T.PCM 1g QID Diluted hydrogen peroxide 1:10 TDS GSH

8. 28/3/24 @ 10am in Ward 4A Still having pain over throat No vomiting No bleeding overnight BP 109/80 HR 87 T 37 SpO2 98% RA PS 2 Oral cavity: No blood clot or active bleeding. Slough at bilateral tonsillar bed Plan : Cont IV Augmentin Cold saline gargle Soft cold diet Watchout for bleeding, to inform STAT If tolerating orally by pm , for normal diet .

9. 28/3/24 @ 4pm in Ward 4A Informed by SN , Patient had one episode of bleeding with blood clots Attended stat by medical officer Started patient on cold saline gargle and h202 gargle Post gargle 30 mins : still oozing over left superior pole of tonsillar bed Decided to post case for EUA and Hemostasis Reviewed by Specialist about 45 mins post gargle : no more active bleeding but noted raw area over left tonsillar bed Reassessed about one hour after gargle : no bleeding/ no clots seen PLAN Not for EUA/ Hemostasis yet I/V/O bleeding stopped Watchout for bleeding, to inform STAT KNBM with IVD Repeated FBC HB 12.8 WBC 9.5 PLT 451

10. 29/3/24 @ 9AM in Ward 4A NBM No bleeding No fever Pain tolerable BP 119/74 PR 82 T 37 Oral cavity: bilateral tonsillar bed slough. No active bleeding/blood clot Plan: Cont observation For fluids only till pm Allow tonsillar diet after pm Off IVD Cold saline gargle Inform STAT if bleeding

11. 30/3/24 @ 10AM in Ward 4A tolerate soft diet No per oral bleeding Oral cavity: slough at tonsillar bed. No blood clot Plan: Encourage orally as tolerated Cont iv augmentin Aim discharge PM if no more bleeding after tolerating solid food

12. 30/3/24 @ 3pM in Ward 4A Tolerating normal diet No per oral bleeding Oral cavity: clear. No blood clot. No active bleeding Plan: Allow discharge TCA 1/52 T.Augmentin 625mg BDx 1/52 T. pcm Difflam gargle

13. Possible areas for improvement Emphasize on important to eat after discharge home Emphasize on TCA STAT if bleeding