Inflamed

PAULA JANINA S. CABADING

Post Graduate Intern
Agenda General Data
1

2 History

3 Physical Examination

4 Differentials

5 Case Discussion

6 CEA Approach

7 PFC Matrix
Objectives
Recognize acute tonsillopharyngitis in a
patient through a thorough history and
physical examination

Present differential diagnosis for acute

tonsillopharyngitis
Know the causes of acute
tonsillopharyngitis
Discuss the diagnostic approach for acute
tonsillopharyngitis
 General Data
Chief Complaint:

Sore throat

J.A.
38/M
Married
Solsona, Ilocos Norte
History of Present Illness
2 Days PTC 1 Day PTC
Onset of sore throat Still with the aforementioned
associated with difficulty symptoms with
swallowing and chills. undocumented fever.
Self-medicated with Consulted at Piddig District
Paracetamol which offered hospital. Advised to be
admitted for his antibiotic.
temporary relief of
Patient refused. And was sent
symptoms.
home with the ff meds:
No consult done
Celecoxib 200mg BID
Paracetamol 500mg Q4
Co-Amoxiclav 625mg BID
History of Present Illness
Few hours
PTC
Due to persistence of
symptoms now with
odynophagia, he sought
consult.
No cough, colds, diarrhea
and hemoptysis.
 Past Medical History
(-) Hypertension
(-) DM
(-) TB
(-) Malignancy
(-) Hospitalizations
(+) Covid Vaccine
Ist dose: Astrazeneca
2nd dosee: Astrazeneca
Personal & Social History
Non-smoker
Occasional alcoholic
beverage drinker
Farmer
Nonpromiscous male
No history of travel
Family Genogram
Gomez Family
Capurictan, Solosona, I.N.
2 PM

II

III
Family Map
 Review of Systems
General: (-) Weight loss, (-) Weakness
Skin: (-) Rashes, (-) Lumps, (-) Itching (-) Color Change, (-) easy bruising (-) dryness
HEENT: (-) headache, (-) Blurring of vision, (-) Stuffiness, (-) Tinnitus, (-) Hoarseness
Respiratory: (-) Cough, (-) Hemoptysis, (-) Dyspnea,
Cardiovascular: (-) Palpitation, (-) Shortness of breath, (-) Chest pain, (-) Orthopnea
Gastrointestinal: (+) Dysphagia, (-) Nausea, (-) Constipation, (-) Vomiting, (-) Diarrhea
GUT: (-) urgency, (-) hematuria, (-) polyuria
Endocrine: (-) Cold intolerance, (-) Heat intolerance
Neurologic: (-) Dizziness, (-) Fainting, (-) Seizure, (-) Numbness
Musculoskeletal: (-) Muscle pain (-) Joint pains
Physical Exam
HR: 80
RR: 20
Temp: 37.9
•BP: 120/80 mmHg
•O2 sat: 98%
Physical Exam
Physical Exam
Differential Diagnosis
Pharyngitis (Bacterial vs Viral)
COVID-19
GERD
Retained foreign body
Approach
to
Diagnosis
Approach to Diagnosis
 General Data
Primary Working Impression

Acute
Tonsillopharyngitis
Exudative
Case
Discussion
 Acute Tonsillopharyngitis
Infection or irritation of the
pharynx or tonsils
The etiology is usually
infectious, with most cases
being of viral origin and most
bacterial cases attributable to
group A streptococci (GAS).

Pichichero, M. (2007, March 23). Clinical Management of Streptococcal Pharyngitis (1st ed.). Professional Communications, Inc.
 Acute Tonsillopharyngitis
Sore throat is usually a self-limiting
condition that lasts about a week.
In most cases it is caused by a virus but,
in a few people, sore throat is caused by
bacterial infection, usually group A
streptococcus (strep A).
Sore throat usually does not need
antibiotic treatment, regardless of the
cause (viral or bacterial).

NICE Project Team. (2019, November 14). Rapid tests for group A streptococcal infections in people with a sore
throat. National Institute for Health and Care Excellence.
 Acute Tonsillopharyngitis
The most common cause of bacterial
infection is strep A, accounting for about
80% of bacterial infections.

The remaining 20% of bacterial infections

are usually caused by group C and G
streptococcus.

NICE Project Team. (2019, November 14). Rapid tests for group A streptococcal infections in people with a sore
throat. National Institute for Health and Care Excellence.
 Acute Tonsillopharyngitis
Most cases of strep A infection resolve without complications.
Rare complications
Rrheumatic fever
Post-streptococcal glomerulonephritis
Necrotising fasciitis
Scarlet fever
Sepsis or streptococcal toxic shock syndrome

NICE Project Team. (2019, November 14). Rapid tests for group A streptococcal infections in people with a sore
throat. National Institute for Health and Care Excellence.
 Acute Tonsillopharyngitis

Pichichero, M. (2007, March 23). Clinical Management of Streptococcal Pharyngitis (1st ed.). Professional Communications, Inc.
 Guideline for the management of acute sore throat
ESCMID Sore Throat Guideline Group
Clinical assessment of acute sore throat

The Centor clinical scoring system can help to identify those patients who have a
higher likelihood of group A streptococcal infection.

However, its utility in children appears lower than in adults because of the
different clinical presentation of sore throat in the first years of life.

Grigoryan, L., Galeone, C., Esposito, S., Huovinen, P., Little, P., & Verheij, T. (2012, April). Guideline for the management of acute sore throat. Clinical Microbiology and
Infection, 18, 1–27. https://doi.org/10.1111/j.1469-0691.2012.03766.x
 Guideline for the management of acute sore throat
ESCMID Sore Throat Guideline Group
Laboratory tests for sore throat
Throat culture is not necessary for routine diagno- sis of acute sore throat to
detect group A streptococci

If RAT is performed, throat culture is not neces- sary after a negative RAT for the
diagnosis of group A streptococci in both children and adults

In patients with high likelihood of streptococcal infections (e.g. 3–4 Centor

criteria) physicians can consider the use of RATs. In patients with lower
likelihood of streptococcal infections (e.g. 0–2 Cen- tor criteria) there is no need
to routinely use RATs

Grigoryan, L., Galeone, C., Esposito, S., Huovinen, P., Little, P., & Verheij, T. (2012, April). Guideline for the management of acute sore throat. Clinical Microbiology and
Infection, 18, 1–27. https://doi.org/10.1111/j.1469-0691.2012.03766.x
 Guideline for the management of acute sore throat
ESCMID Sore Throat Guideline Group
Laboratory tests for sore throat
It is not necessary to routinely use biomarkers in the assessment of acute sore
throat

Clinical scoring systems and rapid tests can be helpful in targeting antibiotic use.

Grigoryan, L., Galeone, C., Esposito, S., Huovinen, P., Little, P., & Verheij, T. (2012, April). Guideline for the management of acute sore throat. Clinical Microbiology and
Infection, 18, 1–27. https://doi.org/10.1111/j.1469-0691.2012.03766.x
 Guideline for the management of acute sore throat
ESCMID Sore Throat Guideline Group
Treatment
Either ibuprofen or paracetamol are recommended for relief of acute sore throat
symptoms

Use of corticosteroids in conjunction with antibiotic therapy is not routinely

recommended for treat- ment of sore throat. It can however be considered in
adult patients with more severe presentations, e.g. 3–4 Centor criteria

Zinc gluconate is not recommended for use in sore throat

There is inconsistent evidence of herbal treatments and acupuncture as

treatments for sore throat
Grigoryan, L., Galeone, C., Esposito, S., Huovinen, P., Little, P., & Verheij, T. (2012, April). Guideline for the management of acute sore throat. Clinical Microbiology and
Infection, 18, 1–27. https://doi.org/10.1111/j.1469-0691.2012.03766.x
 Guideline for the management of acute sore throat
ESCMID Sore Throat Guideline Group
Treatment
Antibiotics should not be used in patients with less severe presentation of sore
throat, e.g. 0–2 Centor criteria, to relieve symptoms.

In patients with more severe presentations, e.g. 3–4 Centor criteria, physicians
should consider discussion of the likely benefits with patients.

Modest benefits of antibiotics, which have been observed in group A b-haemolytic

streptococcus-positive patients and patients with 3–4 Centor criteria, have to be
weighed against side effects, the effect of antibiotics on the microbiota, increased
antibacterial resistance, medicalization and costs.

Grigoryan, L., Galeone, C., Esposito, S., Huovinen, P., Little, P., & Verheij, T. (2012, April). Guideline for the management of acute sore throat. Clinical Microbiology and
Infection, 18, 1–27. https://doi.org/10.1111/j.1469-0691.2012.03766.x
 Guideline for the management of acute sore throat
ESCMID Sore Throat Guideline Group
Treatment
If antibiotics are indicated, penicillin V, twice or three times daily for 10 days, is
recommended.

There is not enough evidence that indicates shorter treatment length.

Grigoryan, L., Galeone, C., Esposito, S., Huovinen, P., Little, P., & Verheij, T. (2012, April). Guideline for the management of acute sore throat. Clinical Microbiology and
Infection, 18, 1–27. https://doi.org/10.1111/j.1469-0691.2012.03766.x
Overview | Sore throat (acute): antimicrobial prescribing | Guidance | NICE. (2018, January 26). Retrieved September 21, 2022, from https://www.nice.org.uk/guidance/ng84
Overview | Sore throat (acute): antimicrobial prescribing | Guidance | NICE. (2018, January 26). Retrieved September 21, 2022, from https://www.nice.org.uk/guidance/ng84
Overview | Sore throat (acute): antimicrobial prescribing | Guidance | NICE. (2018, January 26). Retrieved September 21, 2022, from https://www.nice.org.uk/guidance/ng84
Overview | Sore throat (acute): antimicrobial prescribing | Guidance | NICE. (2018, January 26). Retrieved September 21, 2022, from https://www.nice.org.uk/guidance/ng84
 CEA Approach
Catharsis Education Action

"Nakatumarak maysa jay Explain to the patient Patient counseling

antibiotic kon ngem nasakit that it may take 3-4 days regarding the proper way
met latta tay karabukob ko." for the antibiotics to of taking medications
show their effect. Involving the family
"Isardeng ko gamin agtumar Emphasize the member as a therapeutic
tay antibiotic kon doc nu importance of antibiotic ally in ensuring patient's
awan mariknakon" resistance compliance
 PFC Approach
Patient-Centerd Family Focused Community Oriented

Referred to RHU for

Analgesics follow up
Ensure patient
Anti-pyretic Emergency admission if
compliance to
Antibiotic airway compromise
medications by involving
Hydration Referral if necessary to
the family members as
Importance good oral specialists:
therapeutic ally
hygiene ORL-HNS
Gastroenterologist
References
Leopando et al, Textbook of Family Medicine Volume 1 (Principles, Concepts,
Practice and Context) and Volume 2 (Enhancing the Performance of the Five
Star Family Physician)
Overview | Sore throat (acute): antimicrobial prescribing | Guidance | NICE.
(2018, January 26). Retrieved September 21, 2022, from
https://www.nice.org.uk/guidance/ng84
Pichichero, M. (2007, March 23). Clinical Management of Streptococcal
Pharyngitis (1st ed.). Professional Communications, Inc.