My throat hurts!

[Flight-LP]

I've had a few interesting cases recently, lets see what others think...............

48 y/o black male presents with a sore throat x 3 days. Pt. tells you he was evaluated the day before and diagnosed with acute pharyngitis. Pt. was given Claritin and Cepacol the day before. Today he advises it feels like he is choking when he lies down and his sore throat has worsened.

Pt. is A&O x4, skin is warm, pink, and dry. Pt. is unable to open his mouth sufficiently to completely visualize the oropharynx. You do however notice severe edema to both tonsils which partially obstruct the uvulla.

Vitals are: B/P 140/96
P 100
R 24
T 100.6
BGL 93mg/dl
SPO2 99%

What do you think? What else would you assess? How would you treat?

Enjoy......................

 

[BossyCow]

First off leave him sitting up. Sort of a "Doctor, it hurts when I do this" thing. When did he last take meds. Claritin formulas can be slow acting. I'd probably just do a general pe, vitals and transport to the ER. Since the swelling may impacting his airway, I'd watch him real close, monitor his O2 sat, resp rate and take him in.

 

[rhan101277]

I wonder why he was not given anything for anti-inflammatory.

 

[KEVD18]

yeah, steroids and antibiotics sounded like a really good idea. then again, when he presented to the md, his swelling might not have been that bad and not warranted treatment that aggressive.

last year, i had a sore throat that i let go for just about two weeks. it got to the point where i coudlnt eat anything other than milkshakes, barely talk and was staring to have some breathing difficulties. finally dragged myself to the er. prednisone for the swelling and avelox for the infection.

 

[mycrofft]

Hmmmm... zebras?

Any other potentially neuro deficits other than unable to open mouth? Recent lac, puncture, or foreign object into eye etc? When was latest tetanus immunization? (Don't ask "When was your latest?", ask "Do you remember when you last had a tetanus shot?" then if they say yes, ask "Where, when, and why?") (R/O tetanus).

Has pt recently been immunized against a viral agent? Was his posterior pharyngeal complaint supposed to be viral, bacterial, or allergic? Are potentially neuro inabilities seeming to move down from head to torso, etc? (R/O Guillame-Barre?)

Eating risky home-stored meals like string beans, beets corn or other low acid materials? Ditto wound questions above, can be up to about ten days post injury (R/O C. botulinum exotoxicity , aka "botulism").

Use an otoscope to try to observe uvula for swelling.

I'm tapped. Maybe just really bad abcessed tonsils, and damn the zebras. Be ready to "tube and bag" at any rate.

 

[Ridryder911]

Tell your partner its his call. Could be epiglottitis (yes, even adults get it), peritonsillar abscess... no matter what with angionuerotic edema bad joo joo... Try to obtain a better history. Just wondering how are the lung sounds and if the patient has a hx of ACE inhibitors as well?

R/r 911

 

[Flight-LP]

No recent immunizations, no need for ABx therapy of anti-inflammatories as the initial presentation was viral (although he did get steroids by the time we were done with him). No pustules or exudate on the tonsils that could be visualized.
No recent wounds.
No botulism.
No tetanus.
No neuro deficits.
Is on Lisinopril (funny you mention that one RID, had an angioedema pt. the next day with lips and a face like a baboon. Courtesy of............you guessed it, his ACE inhibitor. Very interesting presentation)
No visual swelling to the uvulla, but again, it wasn't completely visible.

Good responses! Any other guesses?

 

[mycrofft]

Peritonsilar abscess with associated Lemier's Disease

(Mystery Diagnosis, TLC 2007)

 

[Flight-LP]

Nope, but creative thought! I was actually concerned about a peritonsillar abscess at first until he showed his final sign and symptom......................

He was unable to swallow and maintain secretions in his mouth (i.e. he started drooling) and exhibited pronounced bilateral lymphadenopathy to his anterior, posterior, and submandibular lymph nodes.

Things went from bad to worse!

 

[Ridryder911]

Ask my partner, "It sucks to be in charge, huh?"...

R/r 911

 

[Outbac1]

Could it be as simple as Mono or the Mumps?

 

[Flight-LP]

Could it be as simple as Mono or the Mumps?

god I wish it was! But no...........................

 

[traumateam1]

Has you patient had any possible exposure to someone with a possible infectious illness? Does he have a hx of long term alcohol use or hx of long term smoking?

 

[traumateam1]

Oh right! As far as MY treatment, being limited n all, I would be ready to bag this guy, and hope he's not to swollen in there for me to pop an OPA in. I would give him O2 via NC as of now, can always give him a mask later on if his resps get bad, or worse. Put him on the stretcher, and go. Of course, not knowing what's going on.. and maybe it's because I really don't have the knowledge.. I would put on a N-95 mask.. I would like to hear from some others what they think about that.

 

[Flight-LP]

Oh right! As far as MY treatment, being limited n all, I would be ready to bag this guy, and hope he's not to swollen in there for me to pop an OPA in. I would give him O2 via NC as of now, can always give him a mask later on if his resps get bad, or worse. Put him on the stretcher, and go. Of course, not knowing what's going on.. and maybe it's because I really don't have the knowledge.. I would put on a N-95 mask.. I would like to hear from some others what they think about that.

Nothing infectious............

 

[traumateam1]

Does he have a hx of long term alcohol use or hx of long term smoking?

Is there any possibility of this?

 

[Flight-LP]

Nope, neither........................

 

[Sapphyre]

I'm going to longshot here. (feel free to laugh, this one's coming courtesy of Ocean Force) Stroke?

 

[Flight-LP]

Again, no neuro deficits...................

 

[Flight-LP]

As usual, Rid got this one!

Pt. was treated by us with 125mg Solu-Medrol IVP, and 1Gm Rocephin IM. Pt. was placed on continuous Combivent treatments which did not resolve his dyspnea and he was then given nebulized Epinephrine 3mg/3ml which started to open him back up. Pt. was transferred to the local military medical facility where a soft tissue neck film revealed severe thickening to his epiglottis, along with edema to his prevetebral soft tissues. Pt was subsequently flown to the nearby Combat Surgical Hospital where he was admitted to ICU. A neck CT confirmed the diagnosis of epiglottitis and blood cultures revealed a group F B-Hemolytic Streptococcus as the causitive agent. Interestingly enough, our initial Strep A test was negative (we now know why!). The pt. received 3 days of Clindamycin and was eventually returned back to work.

Very interesting case! What originally appeared as a typical viral pharyngitis quickly changed overnight. Just goes to show, never brush off those sore throat calls!