MAJOR CASE 3

Trigger Problem:

K.P., a 26-year-old female call center agent came in the outpatient clinic for odynophagia
of 3 days duration

1. Using as guide the mnemonic for history taking, CLITAA (Character, Location,
Intensity, Timing, Associated Signs/Symptoms, Aggravating Signs/Symptoms), what
information would you want to know from the patient?

HANDOUT 1
HISTORY OF PRESENT ILLNESS

K.P, a 26-year-old female call center agent from Batangas City who came in the
outpatient clinic for odynphagia of 3 days duration

Two days prior to consult, the patient had sudden onset of pain upon swallowing, slightly
burning in character, 3/10 in the pain scale, upon waking up in the morning. She was still
able to eat her usual breakfast of cereals and went on to her job in the call center. She was
advised by her colleague to gargle with warm saline solution for the sore throat which she
did and afforded minimal relief. No consult nor other intervention was done.

One day prior to consult, pain upon swallowing increased to a pain score of 6/10. She had
fever recorded at Tmax 38°C. She took Paracetamol 500mg/tab 1 tab every 4 hours
providing relief of the fever. She could only take milk and water due to the pain. The
patient continued with the warm saline solution. She was able to go to work but was
bothered with pain on her right ear. She went to the office clinic and was advised to
continue intake of Paracetamol as needed for the fever or pain and to seek consult with a
physician. The patient just went home and rested.

Few hours prior to consult, the patient woke up from intense throat pain, now noted to be
9/10 on the pain scale. There was pain with just swallowing her saliva. She was feeling
weak and feverish and was not able to check the temperature. She also noted muffling of
her voice. She went to the hospital emergency room immediately for consult.

Review of Systems:
(-) cough, (-) colds, (-) difficulty of breathing

Social History:
Occasional smoker, occasional alcoholic beverage drinker
No previous history of throat infection
No previous history of admissions or surgeries

2. What is your initial impression? What events or symptoms noted in the history of the
patient led you to this impression?

3. Enumerate your differential diagnoses? Explain.

HANDOUT 2
PHYSICAL EXAMINATION

Temp: 39 °C BP: 120/80 HR: 110/ min RR: 23/min O2 sat: 98% at room air

Ears:
AU: No pain on tragal manipulation, no mastoid tenderness. Normal looking pinna,
patent EAC, (+) cone of light, intact tympanic membrane

Nose: No nasal congestion turbinates. No nasal discharge. Midline septum. No masses.

Oral Cavity and Oropharynx: Dry lips. Moist buccal mucosa. No dental caries. No
masses or lesions on buccal mucosa, upper and lower alveolar ridges, retromolar trigone,
floor of the mouth, tongue and hard palate. Hyperemic Grade 3 palatine tonsils with
exudates. No sagging or fullness of soft palate. Uvula midline. Hyperemic posterior
pharyngeal wall. (+) Muffling of voice.

Neck: 1.5cm in widest diameter palpable mass, firm, movable, tender on palpation on
Level II, Right. 1cm in widest diameter palpable mass, firm, movable, slightly tender
mass on Level IB.

Lung: Clear breath sounds, no wheezes

Heart: adynamic precordium, distinct S1 and S2, tachycardic, regular rhythm, (-)
murmurs
Abdomen: flat, soft, nontender with no palpable masses.
Extremities: full and equal pulses, (-) clubbing

4. Why did the patient have ear pain when the physical exam of the ears was normal?

5. What are the subsites of the oral cavity?

6. What structures are seen in the oropharynx?

7. What is the Waldeyer’s ring?

8. What is the grading system used in measuring the palatine tonsils?

9. Describe the boundaries and contents of the triangles of the neck.

10. What are the different cervical lymph node levels? Infections of the palatine tonsils
usually drain into what level/s of lymph node?

11. What is the pathophysiology of acute tonsillopharyngitis?

12. What ancillary tests would you request? Explain the importance of each test.
HANDOUT 3
DOCTOR’S ACTIONS

The doctor requested for a CBC with the following result:

Hb 130/Hct 35/ WBC 16.1/ Neutrophils 80/ Lymphocytes 20/ Platelet 351/
Normochromic, Normocytic

The patient was hydrated intravenously with PNSS 1L to run for 8 hours. Piroxicam 2
wafer tabs were given sublingually at the emergency room decreasing the pain to 5/10.
The patient was subsequently admitted. Antibiotic treatment was initiated with Co-
Amoxiclav 600mg IV Q8. Other medications given were Povidone + iodine oral
antiseptic 5-10 ml TID every after meals and Celecoxib 200mg/cap BID. The patient was
put on soft diet and was monitored accordingly.

13. Interpret the CBC result.

14. Given the history, PE and ancillary test, what is your impression?

15. How would you manage the condition? Is there an indication for admission?

16. What is the most common microorganism that causes ATP? How would you treat this
empirically?

HANDOUT 4: COURSE IN THE WARDS

Upon admission, the patient was feeling better with odynophagia at PS 4/10. She was
afebrile and was tolerating soft diet.

On the 1st hospital day, the patient had stable vital signs, afebrile. Odynophagia was
decreased to PS 3/10. Her voice no longer sounded muffled. On physical examination,
the palatine tonsils were slightly hyperemic with noted decrease in exudates. Her cervical
lymhadenopathies were slightly tender on palpation. The patient had good fluid intake.

On the 2nd hospital day, the patient had stable vital signs. No pain was noted. Patient was
able to tolerate regular diet. Clearing of the exudates was noted on the grade 2 palatine
tonsils which were non hyperemic on examination. Repeat CBC was done which showed:
Hb 129/ Hct 34/ WBC 7.6/ Neutrophils 65/ Lymphocytes 30/ Monocytes 2/ Eosinophil 1/
Platelet 340/ Normochromic, Normocytic. Patient was deemed fit for discharge with
home medications of Co-Amoxiclav 625mg/tab 1 tab Q8 to complete 1 week, Celecoxib
and oral antiseptic. Patient was for follow up after 1 week.

17. What are the complications of ATP?

18. If the ATP worsened and progressed to peritonsillar abscess, how will you manage it?

 END 