QUIRINO MEMORIAL MEDICAL CENTER

PROJ. 4, QUEZON CITY

DEPARTMENT OF PEDIATRICS

A CLINICAL CASE

PRESENTED BY:

ANDY M. MARTINEZ
JAMES B. TAMAYO
REGIL O. TORRES
IDENTIFYING DATA:
D. T.
6 years old
Female
Filipino
Roman Catholic
Right handed
San Roque, Quezon City
Birthday: April 5, 2006
QMMC: October 04, 2012 at around 8:40 pm

INFORMANT:


Patient herself and mother
CHIEF COMPLAINT:
Fever of 4 days duration

HISTORY OF PRESENT ILLNESS :
4 days PTC:
Fever (Tmax: 38.2 C)
Headache: unilateral, frontal in location, non radiating, 5/10,
pulsating
Poor appetite, weak-looking
No cough, colds, muscle pain, difficulty of breathing, chest pain
Paracetamol 250mg/5ml, 5ml syrup every 4 hours temporarily
relieved
No consult
2 days PTC:
Still with fever (Tmax: 38.7 C)
Headache: unilateral, frontal in location, non radiating, 7/10,
pulsating
Poor appetite, weak-looking
Non productive cough, no phlegm
Sore throat
1 episode of vomiting (undigested food)
Abdominal pain: 5/10, pricking, non radiating
Paracetamol 250mg/5ml, 5ml syrup every 4 hours temporarily
relieved
No consult







1 day PTC:
Persistence of the above symptoms
Consult admission
MATERNAL AND BIRTH HISTORY:
35 y/o G4P4 (4004) via NSD
Full termed and planned pregnancy
4x prenatal check up at QMMC
No tobacco, drugs and alcohol use
No fetomaternal illnesses during pregnancy. No vaginal
bleeding.
No infectious diseases such as fever, cough or colds contracted
during her pregnancy.
OBSTETRIC HISTORY: G4P4 (4004)
Year MOD Where Sex Complications
G1 1999 NSD QMMC Male None
G2 2003 NSD QMMC Male None
G3 2006 NSD QMMC Female None
G4 2008 NSD QMMC Female None
NEONATAL HISTORY :
Estimated weight of 8 lbs
No congenital anomalies
Pink color with a loud cry
No cyanosis
The child was breastfed

FEEDING HISTORY:
Infancy:
Breastfed until 6 months with good suck, no noted feeding
difficulties
Bottle-feeding started using Bona, approximately 6-8 bottles per
day
Introduction of solid foods at 6 months (mashed potatoes)

Childhood:
Eats 3 times a day
Present diet and appetite- likes eating chicken, hotdog and eggs

DEVELOPMENTAL HISTORY:
Smiles in response to voice at 2 months
Grasp objects at around 4 months
Crawl and sit at around 5 - 6 months
Follow command with gesture at 7 - 8 months
Roll over - 5 months
Speech- 6 months
Hold a bottle - 7 months
Reach out to objects - 9 months
Walk alone - 1 year
Jump - 2 years
Plays and watches TV with his mother everyday
IMMUNIZATIONS:
Immunizations complete
BCG 0.05ml ID at 1
st
month
Hepa B 0.5ml IM at birth, 1
st
, 6
th
months
Measles 0.5ml SC at 9
th
months
DPT 0.5ml IM at 2
nd
, 4
th
, 6
th
months
OPV 2-3 drops at 2
nd
, 4
th
, 6
th
months
No adverse reactions to the immunizations given



PAST MEDICAL HISTORY :
No history of asthma, TB, pneumonia, diabetes,
hypertension
No allergies to foods or medication
History of exposure to throat infection - brother, Sept. 30,
2012
No past hospitalization or surgeries
FAMILY HISTORY :
(-) Allergy
(-) Asthma
(-) DM
(-) PTB
(-) HTN
(-) Cancer
(-) CVD
(-) Thyroid disease
(-) Kidney disease

FAMILY GENOGRAM:
Dimpas, Family
As of October 4, 2012
San Roque, Quezon City
1995
Ron, 15
Susan,35 Susan,32 Jeffrey,29
Tricia,6 Rey, 10
Reynaldo, 38
Rachelle, 3
Legend:


Throat infection, September 30, 2012

index patient
Rey, 55 Rosaly, 56
SOCIAL HISTORY:
Lives with other 6 family members
Water source (NAWASA)
Garbage is collected twice a week
Good interpersonal relations with her brothers and sisters
Good living condition

REVIEW OF SYSTEM:
Skin:
(-) Itchiness
(-) Excessive dryness
(-) Pallor

Head:
(-) Dizziness

Eyes:
(-) Photophobia
(-) Excessive lacrimation
(-) Photophobia
(-) Diplopia
(-) Eye pain
(-) Loss of vision
(-) Double vision

Ears:
(-) Changes in hearing
(-) Tinnitus
(-) Discharge
(-) Otalgia

Nose:
(-) Changes in smell
(-) Epistaxis
(-) Obstruction
(-) Colds
Mouth and throat:
(-) Gum bleeding
(-) Tooth ache
(-) Changes in taste


Respiratory System:
(-) Sputum production
(-) Hemoptysis
(-) Difficulty of breathing

Cardiovascular System:
(-) Orthopnea
(-) PND
(-) Palpitations
(-) Syncope
(-) Easy fatigability



Gastrointestinal System:
(-) Diarrhea
(-) Hematemesis
(-) Constipation
(-) Melena
(-) Hematochezia

Genito-urinary Tract:
(-) Urinary frequency
(-) Incontinence
(-) Genital puritus
(-) Dysuria
(-) Hematuria

Endocrine:
(-) Polyuria
(-) Polyphagia
(-) Polydipsia



Hematologic:
(-) Easy bruisability
(-) Abnormal bleeding

Neuromuscular/Musculoskeletal:
(-) Seizure
(-) Weakness

PHYSICAL EXAMINATION UPON ADMISSION:
General Survey: awake, conscious, coherent, ambulatory, not
in cardio-respiratory distress

Vital signs:
BP: 90/60
CR: 100 bpm
RR: 24 b/m
Temp: 38. 3 C
Weight: 24 kgs


PHYSICAL EXAMINATION:
HEENT: Normocephalic, no head injuries, anicteric sclera,
pupils are reactive to light, nasal mucosa pink, no polyps,
septum is midline, oral mucosa is pink, hyperemic and
swollen tonsils, no pharyngeal exudates, tongue midline,
supple neck, no CLAD

Chest/Lungs: No masses or scars. Symmetric chest wall
expansion, no retractions, clear breath sounds


Cardiovascular: Adynamic precordium, PMI: 5
th
left ICS, regular
rate and rhythm, no murmurs, S1 > S2

Abdomen: Flat, no scars, masses or hyperpigmentations. No
enlarged or dilated veins, no visible pulsations or peristalsis.
NABS, tympanitic. No bruit, rigidity, masses, organomegaly,
mild tenderness. Spleen and kidneys not felt. No
costovertebral angle tenderness (CVAT).

Extremities: No scars or masses. Full equal pulses, no edema
and cyanosis


LABORATORY RESULTS:
Test Result Reference range
RBC 4.41 4.20 - 5.40
Hemoglobin 119 L 120 - 160
Hematocrit 0.36 0.36 - 0.47
MCV 82.2 80 - 96
MCH 26. 9 L 27 - 31
MCHC 32.80 32 - 36
RDW 13.7 11.6 - 14.6
Platelet Count 349 150 - 450
WBC 15.3 H 5.0 - 10.0
Neutrophils 0.835 H 0.500 - 0. 700
Lymphocytes 0.095 L 0.200 - 0.500
Monoctyes 0.068 0.020 - 0.090
Basophils 0.002 0.000 - 0. 020
URINALYSIS :
Color Yellow
Transparency Clear
PH 6.0
Specific Gravity 1.030
WBC 0-2/hpf
RBC 0- 3/ hpf
Albumin negative
Sugar negative
SEROLOGY :
Rapid Test Dengue IgG- negative
IgM-negative
Dengue Antigen Negative
COURSE IN THE WARD :
DAY S O A P
Hospital day 1:
8:45 pm
(+) fever x 4days
(+) sore throat
(+) epigastric pain
(+) headache
BP-90/60
RR: 24
PR: 100 bpm
Temp: 38.2 C

.

ATP r/o DHF I Please admit to
pedia ward.
Secure consent for
admission
management.
DAT + no dark
colored foods.
TPR+ BP Q4 ad
record.
PNSS 1L@ 28
gtts/min.
Labs:
CBC, APC, Dengue
blot, U/A.
Tx:Paracetamol 250
mg/ 5 ml, give 6.5
ml Q4 if fever >37.8
deg cel.
Ranitidine 25 mg
TIV q 8 hrs
DAY S O A P
3:00 am (+) febrile episodes
(+) abdominal pain
(+) hyperemic
tonsils
Fair intake
Full pulses
(-) cough and colds


Temp: 38.5 C


ATP r/o DHF

IVF : PNSS 1L x 30
gtts /ml.
Star Ranitidine
25mg TIV.
Ampicillin 500 mg
TID Q6.
Awaits lab results.

Hospital day 2: Febrile episodes
Comfortable
Good intake
(-) abdominal pain

Temp: 36.7 C


ATP, Non exudative IVF D5NM 1L cc x
25 gtts/min.
Meds: Amipicillin
d/c Ranitidine.
CBC w/ APC

Day S O A P
Hospital Day 3: Afebrile
Comfortable
Good intake
(-) vomiting
Full pulses
Temp-36.8 C

Neutro- 0.374
WBC-7.3


ATP, Non exudative

MGH after result of
CBC.
Hospital Day 4 : Afebrile
Comfortable
Good intake
(-) vomiting
(-) hyperemic
tonsils
Temp-36.7 Cel. ATP, Non exudative


MGH
OPD ff up after 1
week, 7am.
Meds:
Amoxicillin
250mg/5ml, 7.5 ml
TIDx 7 days.
Ascorbic acid ,
250mg/5ml, OD.
SALIENT FEATURES:
6 years old
Fever
Sore throat
Headache
Cough
Abdominal pain
Vomiting
History of exposure to throat infection
Hyperemic and swollen tonsils and pharynx

DIFFERENTIAL DIAGNOSIS:
Acute tonsillopharyngitis
Dengue
Leptospirosis
Diptheria
DENGUE FEVER :
Transmitted by the bite of an Aedes mosquito
Occurs in tropical and sub-tropical areas of the world
Symptoms appear 3-14 days after the infective bite
Symptoms: range from a mild fever, to incapacitating high
fever, with severe headache, pain behind the eyes,
muscle and joint pain, and rash
There are no specific antiviral medicines for dengue. It is
important to maintain hydration.

Dengue haemorrhagic fever (fever, abdominal pain,
vomiting, bleeding) is a potentially lethal complication,
affecting mainly children.

LEPTOSPIROSIS:
Infectious disease caused by a type of bacteria called a
spirochete.
Transmitted by many animals such as rats, skunks,
opossums, raccoons, foxes, and other vermin.
Mode of transmission:
contact with infected soil or water through broken skin
and mucous membrane
ingesting contaminated food or water
Most Common:
Dry cough
Fever
Headache
Muscle pain
Nausea, vomiting, and
diarrhea
Shaking chills

Less common:
Abdominal pain
Abnormal lung sounds
Bone pain
Conjunctivitis
Enlarged lymph glands
Enlarged spleen or liver
Joint aches
Muscle rigidity
Muscle tenderness
Skin rash
Sore throat

DIPTHERIA:
Acute infectious disease caused by the
bacteria Corynebacterium diphtheriae.
Diphtheria spreads through respiratory droplets (such as
those produced by a cough or sneeze) of an infected
person or someone who carries the bacteria but has no
symptoms.
Most commonly infects the nose and throat.
The throat infection causes a gray to black, tough, fiber-like
covering, which can block the airways.
In some cases, diphtheria may first infect the skin,
producing skin lesions.
Risk factors include crowded environments, poor hygiene,
and lack of immunization.

Fever
Chills
Fatigue
Bluish skin coloration
Sore throat
Hoarseness
Cough
Headache
Difficulty/Painful swallowing
Difficulty breathing
Rapid breathing
Foul-smelling bloodstained nasal discharge
Lymphadenopathy
PRIMARY WORKING IMPRESSION:
ACUTE TONSILLOPHARYNGITIS, NON EXUDATIVE
Swelling of the pharynx and the
tonsils.
The pharynx is the back of the
throat, including the back of the
tongue.
Both pharyngitis and
tonsillopharyngitis -- sore throat.

TYPES BASED ON ETIOLOGY:
Viral tonsillopharyngitis:
Inflammatory condition of the tonsils
Cause: respiratory viruses
oadenovirus, influenza, parainfluenza, and respiratory syncitial
virus.
Other viral agents
o include coxsackie, echoviruses, herpes simplex and Epstein Barr
Virus (EBV)

Bacterial tonsillopharyngitis:
Inflammatory condition of the pharynx and or tonsils
Cause:
o Group A beta-hemolytic streptococci (GABHS)
o Hemophilus influenza
o Moraxella catarrhalis


Features suggestive of bacterial etiology:
Sudden onset
Sore throat /Dysphagia
Fever
Petechiae
Headache
Nausea, vomiting, and abdominal pain
Inflammation of pharynx and tonsils
Patchy discrete exudates
Tender, enlarged anterior cervical nodes
Patients aged 5-15 years
History of exposure

Features suggestive of viral etiology:
Conjunctivitis
Coryza
Cough
Hoarseness
Diarrhea

****Highlighted features are adapted from the Centor Criteria****





DISCUSSION
Tonsillopharyngitis:
30% of patients
Group A -hemolytic streptococcus (GABHS) is most
common
But Staphylococcus aureus, Streptococcus
pneumoniae, Mycoplasma pneumoniae, andChlamydia
pneumoniae are sometimes involved
Rare causes:
Pertussis,Fusobacterium,Diphtheria,Syphilis,Gonorrhea

GABHS: occurs most commonly between ages 5 and 15 and
is uncommon before age 3.

Streptococcal tonsillopharyngitis:
Inflammatory condition of the pharynx caused by Group A
beta-hemolytic streptococci
Incubation period: 2 5 days
Most common in children: 5 - 12 years of age
Risk of acute rheumatic fever complicating untreated
streptococcal pharyngitis is 1%.
Assoc. complications: glomerulonephritis and RHD





RISK FACTORS :

Age: children and teens, and people aged 65 years or

older

Exposure: with a sore throat or any other infection

involving the throat, nose, or ears

Exposure: cigarette smoke, toxic fumes, industrial smoke,

and other air pollutants

Hay fever or other allergies and stress

Having other conditions that affect your immune system,

such as AIDS or cancer

SYMPTOMS:

Sore throat

Pain or difficulty when swallowing

Difficulty breathing

Fever

Enlarged lymph nodes in your neck

Hoarse voice

Red or irritated looking throat

Swollen tonsils

White patches on or near your tonsils

Runny nose or stuffy nose

Cough

RECOMMENDATIONS ON THE DIAGNOSIS OF ACUTE AND
CHRONIC TONSILLOPHARYNGITIS
1. The diagnosis of acute tonsillopharyngitis may be made
clinically for both children and adults. It is important to
differentiate whether the infection is viral or bacterial in
etiology.
RECOMMENDATIONS ON THE DIAGNOSIS OF ACUTE
AND CHRONIC TONSILLOPHARYNGITIS
2. The diagnosis of acute group A streptococcal infection
should be suspected on clinical grounds and may be
supported by performance of a laboratory test.

Grade B Recommendation:
Throat culture remains to be the gold standard for the
diagnosis of streptococcal pharyngitis with a sensitivity
of 90-95%.
RECOMMENDATIONS ON THE DIAGNOSIS OF ACUTE
AND CHRONIC TONSILLOPHARYNGITIS
Grade B Recommendation:
A positive rapid antigen detection test (RADT) may be
considered definitive evidence for treatment of
streptococcal pharyngitis, with specificity of 95% and
sensitivity of 89.1%.
These values are similar to those of throat culture
which has a 99% specificity and 83.4% sensitivity.
RADT: not widely available locally and cannot be
considered part of routine diagnostic assessment.
RECOMMENDATIONS ON THE DIAGNOSIS OF ACUTE
AND CHRONIC TONSILLOPHARYNGITIS
Grade C Recommendation
Either a positive throat culture or RADT provides adequate
confirmation of GABHS in the pharynx, but a negative
RADT result should be confirmed with a throat culture
whenever possible.
However, the value of early diagnosis in the minority of
cases when streptococcus is present should be weighed
against the higher cost incurred in testing the majority of
cases seen.
Selective use of diagnostic studies is suggested.



RECOMMENDATIONS ON THE DIAGNOSIS OF ACUTE
AND CHRONIC TONSILLOPHARYNGITIS
3. The diagnosis of chronic tonsillitis can be made by a
history of medically documented episodes of acute
tonsillitis for at least 4 times a year.

Grade C Recommendation
There are four randomized controlled trials (RCT) on
tonsillectomy versus non-surgical intervention studies in
children but no RCT in adults.
More than 5 episodes and American Academy of
Otolaryngology-Head and Neck Surgery more than 3
episodes as indication for tonsillectomy.

RECOMMENDATIONS ON THE DIAGNOSIS OF ACUTE
AND CHRONIC TONSILLOPHARYNGITIS
4. The diagnosis of obstructive adenoidal hypertrophy should
be made on the basis of enlarged adenoids and a
persistent difficult in breathing and/or swallowing.

Grade C Recommendation:

The following may be used in the diagnosis of obstructive
adenoidal hypertrophy:

Anterior rhinoscopy
Posterior rhinoscopy
Intraoral palpation
Soft tissue lateral films of the nasopharynx may be used to
determine the adenoid enlargement but its low sensitivity and the
need for proper radiologic techniques is emphasized


DIAGNOSIS:
Clinical evaluation
GABHS ruled out by rapid antigen test, culture, or both
Blood count and differential count.


TREATMENT/MANAGEMENT:
Antibiotics for strep throat
Drugs to reduce sore throat pain; these drugs include:
Ibuprofen (Motrin, Advil)
Acetaminophen (Tylenol)
Aspirin
Note: Aspirin is not recommended for children or teens
with a current or recent viral infection. This is because of
the risk of Reye's syndrome.
Numbing throat spray
Decongestants and antihistamines
Throat lozenges
Corticosteroids
PROGNOSIS;
Good

COMPLICATIONS;
Rheumatic fever and subsequent rheumatic heart disease
Poststreptococcal glomerulonephritis
Peritonsillar abscess
Systemic infection
Otitis media
Mastoiditis
Septicemia or toxic shock syndrome
Rhinitis
Sinusitis
Pneumonia

HOME CARE :
Get plenty of rest
Drink plenty of water
Gargle with warm salt water several times a day
Drink warm liquids (tea or broth) or cool liquids
Avoid irritants that might affect your throat, such as smoke
from cigarettes, cigars, or pipes, and cold air
Avoid drinking alcohol


PREVENTION:
Wash hands frequently
If someone who had a sore throat, keep his eating utensils
and drinking glasses separate from those of other family
members
If a toddler with a sore throat has been sucking on toys, wash
the toys in soap and water.
If you have hay fever or another respiratory allergy, ask for
consult.
Avoid the substance that causes your allergy.



THANK YOU(,)