CORDILLERA CAREER DEVELOPMENT

COLLEGE
COLLEGE OF HEALTH EDUCATION
BACHELOR OF SCIENCE IN NURSING
Buyagan, Poblacion, La Trinidad, Benguet

CASE ANALYSIS (EENT WARD)

Scenario:

You are on 7-3 shift duty at EENT ward of Benguet General

Hospital, 2nd floor left wing.

Simon, a 22-year-old male patient, was presented because of severe

pain in the throat and the left ear that increased with swallowing of
sudden onset and 3 days duration. He gave a history of sore throat
and fever a few days prior to the condition. On examination, the
patient looked very ill and has a thickened voice. The temperature was
38℃ , the pulse 110 per minute, RR 27 cycle per minute, and SPO2 of
95%. The patient had a strong, musty smell of breath and was unable
to open his mouth. There was marked edema of the palate concealing
the left tonsil that was found infected. There was a painful hot swelling
located below the left angle of the mandible. The left tympanic
membrane was normal. 

I. DIAGNOSIS & REASONS

Acute tonsillitis (sore throat and fever) complicated by
peritonsillar abscess (severe throat pain referred to the left ear,
very ill, thickened voice, fever, strong and musty breath, unable
to open his mouth, edema of the palate, painful hot swelling at
the angle of the mandible)

II. MANIFESTATIONS
 Pain in the left ear
 Thickened voice: due to edema on the palate
 Fetor of the breath: severe dysphagia leading to inability to
swallow saliva together with the presence of an abscess in the
oropharynx
 Unable to open his mouth
 Left tonsil infected: markedly congested due to severe
inflammatory process
 Hot swelling below the left angle of the mandible
 Normal tympanic membrane: there is no acute otitis media
pain in the ear

III. TREATMENT
 Complete blood picture lecocytosis
 CT scan
 Medical treatment: antibiotics, analgesics, antipyretics and
anti-inflammatory drugs
 Tonsillectomy after 2-3 weeks
 These are some common medications prescribed after
surgery.

 Naprosyn / Naproxen / Aleve

Use: Naprosyn is an anti-inflammatory medication that
provides pain relief. It is used for mild to moderate pain
Instructions: Adults: 500 mg PO twice daily. The dose
may be increased to two 500mg tablets in the morning
and one at night when a higher level of analgesic/anti-
inflammatory activity is required.
Precautions: Do not with other anti-inflammatory
medications such as Motrin.
 Tylenol and Oxycodone combination
 Steroids: Decadron(Dexamethasone) Prednisone /
Medrol
 Anti-nausea medication Zofran
 Mouth Wash
IV. REQUIREMENTS:

Formulate the following requirements in the area from the above situation.

1. Case Study Format

1. 1-inch margin on all sides

2. Long bond paper
3. Times New Roman, font size 12
4. Heading: UPPERCASE, Bold,
Centered
5. Contents: Justified
6. 1.5 spacing
7. Every page with page numbers
(i.e. “Page 1 of 13”)

2. NCP

Assessment Explanatio Goals/ Interventions Rationale Evaluation

n of Objectives
problem
Subjective Elaborate on Short term Dx Reason or 1. The goal is
pneumonia purpose for partially met
Objective Long term Tx doing these
actions or 2. The goal is
Nursing interventions fully met
Diagnosis

3. Drug Study

Name of Dosage Mechanism Indication Contra- Adverse Nursing

Drug of Action indication effects Conside-
(common) ration
Generic
Name;
Brand Name;
Classification

4. Journal reading (must be related to the topic) - use separate sheet of

paper here.

Journal Reading Format

1. Summary
2. Reaction
3. Recommendations
a. Nursing Curriculum
b. Nursing Practice
c. Nursing Research
1. 1-inch margin on all sides
2. Long bond paper
3. Times New Roman, font size
12
4. Heading: UPPERCASE, Bold,
Centered
5. Contents: Justified
6. 1.5 spacing
7. Every page with page
numbers (i.e. “Page 1 of 13”)

5. PLAGIARISM IS A CRIME: MAKE SURE TO CITE YOUR SOURCES!

Use APA in-text citation when citing within discussions.