Interesting EENT Case

[chbare]

Interesting case

Twenty three year old male presents to the ER complaining of a very severe sore throat. He states he was seen by his family doctor about 2 days ago with a cough and sore throat. He was diagnosed with an upper respiratory infection and put on a course of Zithromax. He states his throat has become very sore and he states having difficulty swallowing since the onset of his symptoms. Vital signs are; Resp-22 non labored, Pulse- 110 strong at the radial, B/P-110/066, SAO2-97% on room air, Temp-101.3 tympanic, Pain-10/10 to his throat. His physical exam is unremarkable and his lung sounds are clear in all lobes posterior and anterior. He denies any other medical problems or past medical history. The patient has no allergies and denies taking any other medications. What else would you like to know?

Take care everybody,

chbare.

[Eydawn]

Was the throat pain present before beginning the course of zithromax? Did it worsen after taking the antibiotic? Has he ever been placed on antibiotics before? What is his occupation- is he a singer that undergoes a lot of vocal stress, or does he work in an area with volatile chemicals that he could possibly be inhaling, for example? Any unusual exertion, exercise, shouting, excessive screaming/talking etc? Has he ever had throat pain like this before?

Any history of heartburn, vomiting associated with the infection, etc?

That'll do for starters!

Wendy

NREMT-B

[Dustdevil]

When you say the "physical exam is unremarkable," are we to assume that this was a thorough and comprehensive exam, or just a typical EMT-B once over? How do the mouth, lips, tongue, and throat look? Ears? Cervical or axillary adenopathy? Any sort of rash anywhere (sorry kids, but you have to remove clothes for this one!)? Did the previous doctor do a culture or at least a rapid strep, or was the URI a simple empirical diagnosis? Why was he given Zithromax? Seems a poor choice given the history. Is the patient a tobacco product user? What kind, how much, and how long?

[ERDoc]

I think that given the fact that he was dx with a URI, antibiotics, regardless of which one, is a poor choice. I'd like to know what the throat looked like. Was there any stridor?

[chbare]

I will try to answer all of the questions.

Eydawn:

The pain was present when he saw his PCP and did get worse after starting ABO therapy. No unsusal exposure to substances or activities that would cause throat pain. No other medical problems or history. He has neved had throat pain like this.

Dust Devil:

You are correct about the exam, this was a once over my xray vision can see all kind of exam. No rash noted. Unknown if a rapid strep was performed, I believe not because the patient did not say anything about having a throat swab. I glad it did not take long for someont to ask about a detailed EENT exam. His oral mucosa is moist and intact however you note that his left tonsil appears pushed foreward and the patients uvula appears displaced from the unusual position of the tonsil. You do not note any exudate.

ERDoc:

His oral mucosa is moist and intact , however you note that his left tonsil appears pushed foreward and the patients uvula appears displaced from the unusual position of the tonsil. You do not note any exudate. No strider noted.

I hope the additional information helps.

Take care everybody,

chbare.

[Dustdevil]

Sweet. Seen this one too many times. Old fart docs or lazy docs write Amoxil or z-pack for every URI they see without bothering to confirm a specific diagnosis. Consequently, among many other problems, patient ends up with a major peritonsilar abscess that requires major antibiotics and I&D. A lot of those old skool docs are dying off now, but there are always plenty of lazy ones in the new generation to take their place.

[Ridryder 911]

The old "shotgun" antibotic approach. Hate draining those nasty things.. ahhh... the smell !!! Most people do not realize how serious they are as well...

'

Good one & welcome to the forum Chbare !

R/R 911

[chbare]

Excellent! The diagnosis is peritonsillar abscess. I believe it is the most commonly seen neck abscess. The abscess can cause an upper airway obstruction and should be regarded as a priority for treatment. The patient received humidified oxygen, was placed in a position of comfort, and tolerated IV therapy. His vital signs were monitored frequently as well as frequent airway assessments. Initial treatment included; 1000ml of NS over 60 minutes, 30 mg of Toradol IVP, and 1000mg of Ceftriaxone IVPB. Within the hour an EENT doc was consulted and the patient eventually received an I&D. It was well tolerated and he was discharged home a couple of days later. He eventually had an elective T&A. I am glad everybody liked the scenario. I am with you Dirt Devil on clinicians who hand out scripts for URI's without actually putting to work all of those years of assessment skills they should have learned in school, of course when the triage nurse handed me the chart on this patient she told me this was an in and out wimp call. So, I guess the shoe fits allot of people. Thanks for the warm welcome everybody, and take care.

chbare.