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In The Patient's Chart: History of Present Illness: M.K. Is A 20 Year Old Female Presenting To Her Physician, Complaining

M.K. is a 20-year-old female presenting with a sore throat and cough. She has a history of quinsy (peritonsillar abscess) twice in the past year. Her temperature has fluctuated between 97.8-99.2°F. She complains of isolated throat pain without other symptoms. Diagnostic tests including an ECG and chest x-ray were normal, clearing her for a planned tonsillectomy surgery.

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Paul Jackson
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45 views

In The Patient's Chart: History of Present Illness: M.K. Is A 20 Year Old Female Presenting To Her Physician, Complaining

M.K. is a 20-year-old female presenting with a sore throat and cough. She has a history of quinsy (peritonsillar abscess) twice in the past year. Her temperature has fluctuated between 97.8-99.2°F. She complains of isolated throat pain without other symptoms. Diagnostic tests including an ECG and chest x-ray were normal, clearing her for a planned tonsillectomy surgery.

Uploaded by

Paul Jackson
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Name: ____________________________ Sec:________ Score:____/48 Date: ____________

Case Study 3
Tonsillitis

In the Patient’s Chart

History of Present Illness: M.K. is a 20 year old female presenting to her physician, complaining
of sore throat and cough. She has had some hoarseness in her voice over the past few days and
subjective sweats but no documented fever. She has a history of quinsy at least twice last year.
Upon review of systems, she complains of isolated throat pain, without any rhinorrhea, sinus
pressure, or headache. She has been taking her temperature at home, and they have fluctuated
from 97.8oF- 99.2oF.

During care:
Other diagnostic test: ECG and Chest X-ray received and charted, which cleared her for surgery.
Her latest prothrombin time was taken in to which reads 17 seconds.

She was admitted and eventually was scheduled for tonsillectomy. At 8am after your initial
rounds you initiated to complete her preoperative checklist and had an interview with her. At
the time you also administered her preoperative medication of atropine sulfate and nalbuphine
hydrochloride.

After the interview you prayed with her and she was brought to operating room 1 at 845am
per wheelchair.
Please complete the preoperative checklist (28 points) and answer the questions below.
1. What are her preoperative medications for? (10 points)

2. Is there a reason for her surgery not to push through? If YES, what is it and why?
If no, then just write “NO” below. (10 points)

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