ACUTE TONSILLITIS CASE STUDY

Acute Tonsillitis Case Study

Carlos Legra Elias

Advance Pharmacology

Professor: Dr. Carmante Extra.

Florida National University

Week 6 Case Study 2:

Subjective: Ana is a 17-year-old female who presents to your clinic with symptoms of sore

throat, fever, dysphagia, headache, and nasal discharge for 2 days. The fever varies from 99.2 to

100, but this morning her temperature was 100.6 without chills. This morning also she noticed a

mild dry cough. She took 2 Tylenol regular strength earlier before she came to school and the

fever was gone. She denies exposure to upper respiratory infections, nausea, vomiting, diarrhea,

and neck stiffness. She denies previous and current exposure to sexually transmitted infections.

Level of pain 7/10. PMH: Negative. PSH: Negative. Medications: Tylenol PRN. She has no

known allergies. Last menstrual period September 18th. Patient does not smoke, drink, or use

recreational drugs.

Objective:

Constitutional: Patient is alert x3. She appears well for stated age. Appears in moderate pain and

speaks with a muffled voice. Vital signs: 100.2, 88, 18, 118/68, oxygen saturation 98% on room

air, 150lbs, 5’8”.

Physical: HEENT: Normocephalic and atraumatic. Conjunctivae and EOM are normal. Pupils

equal, round, and reactive to light. Vision: Normal. Nose: Nasal turbinates intact with clear

discharge. Ears: Bilateral ears intact. Cervical lymph nodes tender to touch. Cervical range

of motion within normal limits. Oropharynx: Tonsils red, swollen, with moderate white

patches. Surrounding tissues moderately swollen and tender. No drooling, no soft palate
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petechiae, positive halitosis. Cardiovascular: Normal rate and regular rhythm. S1-S2 sounds

audible. No murmurs, no gallops, palpitations, or chest pain. Bilateral pulses present x4

extremities. Respiratory: Respiratory effort and breath sounds are normal. Lungs clear to

auscultation. No SOB, no dyspnea, no wheezing, no rales. Cardiovascular: Spleen size within

normal limits.

Based on subjective and physical assessment answer the following questions:

1. What are the differential diagnosis? Provide ICD codes.

-Infectious mononucleosis: (ICD-10-CM Code B27.9) Most common in slightly

older age group (adolescents) and, unlike acute tonsillitis, does not resolve after 1

week. It is associated with generalized lymphadenopathy, splenomegaly, and

hepatomegaly, and persistent weight loss and fatigue. Rarely, the swelling of the

pharyngeal tissues may become so significant as to impair breathing. Heterophile

antibody testing is most commonly used to diagnose infectious mononucleosis.

However, it has only moderate sensitivity, particularly in the first week of

symptoms; sensitivity is even lower in children than it is in adults (Gahleitner C,

Hofauer B, Stark T, 2016).

-Epiglottitis:( ICD-10-CM Code J05.1) A child with epiglottitis will have a

muffled voice and will be drooling; there may be stridor and difficulty in

breathing. On suspicion of epiglottitis, it is important not to spend time performing

blood tests or even attempting to examine the child's throat: prompt consultation

with a pediatric anesthetist to secure the airway is crucial (Gahleitner C, Hofauer

B, Stark T, 2016).
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-Peritonsillar abscess (quinsy): (ICD-10-CM Code J36) Causes more severe

symptoms, including trismus, a muffled voice, a displaced uvula, and an enlarged,

displaced tonsil, with swelling of the peritonsillar region. The diagnosis is based

on examination of the oropharynx and is confirmed on needle aspiration of pus

from the peritonsillar swelling (Gahleitner C, Hofauer B, Stark T, 2016).

-Retropharyngeal abscess: (ICD-10-CM Code J39.0) Symptoms may be similar

to those of a severe sore throat. However, the symptoms do not resolve after a few

days, and there may be trismus or visible neck swelling. Elevated C-reactive

protein may be a predisposing factor. Exclusion is made on the basis of lateral

neck radiograph, or neck CT or ultrasound (Gahleitner C, Hofauer B, Stark T,

2016).

-Gonococcal pharyngitis: (ICD-10-CM Code A54.5) Adolescent and adult

patients with a history of oral-genital sex. Throat culture (in Thayer-Martin

medium) of Neisseria gonorrhoeae (Gahleitner C, Hofauer B, Stark T, 2016).

-Diphtheria: (ICD-10-CM Code A36) Examination of the oropharynx reveals the

typical gray-green membrane. Serosanguineous nasal discharge will be noted.

Patient will not have been immunized against diphtheria (Gahleitner C, Hofauer B,

Stark T, 2016).

2. What is definitive diagnosis? Provide rationale and ICD codes.

-Acute tonsillitis. ICD-10-CM Diagnosis Code J03.90

There are several types of tonsillitis, and there are many possible symptoms that

include (Windfuhr JP, Toepfner N, Steffen G, 2016):

 a very sore throat

 difficulty swallowing or painful swallowing

 a scratchy-sounding voice

 bad breath

 fever

 chills

 earaches

 stomachaches

 headaches

 a stiff neck

 jaw and neck tenderness due to swollen lymph nodes

 tonsils that appear red and swollen

 tonsils that have white or yellow spots

In very young children, you may also notice increased irritability, poor appetite, or

excessive drooling.

There are two types of tonsillitis:

 recurrent tonsillitis: multiple episodes of acute tonsillitis a year

 chronic tonsillitis: episodes last longer than acute tonsillitis in addition to other symptoms

that include:

 chronic sore throat

 bad breath, or halitosis

 tender lymph nodes in the neck

3. What diagnostic tests will you order for this patient? Rationale for ordering the tests.

Provide CPT codes.

Diagnosis is based on a physical examination of your throat. The doctor may

also take a throat culture and sensitivity (CPT Code(s) 87070) by gently swabbing

the back of your throat because the patient has Tonsils red, swollen, with

moderate white patches. Surrounding tissues moderately swollen, tender and

positive halitosis. The culture will be sent to a laboratory to identify the cause of

your throat infection. Other test to consider can be WBC count and differential

(CPT Code(s)85004, 85048), heterophile antibodies (CPT Code 86308) and rapid

streptococcal antigen test (CPT Code 87880) (Windfuhr JP, Toepfner N, Steffen

G, 2016).

4. What is your treatment plan/interventions for this patient? Provide rationale for

your choice(s).
ACUTE TONSILLITIS CASE STUDY

A mild case of tonsillitis does not necessarily require treatment, especially if

a virus, such as a cold, causes it. Treatments for more severe cases of tonsillitis

may include antibiotics or a tonsillectomy.

Antibiotics are indicated for patients with group A beta-hemolytic streptococcal

infection confirmed on antigen testing and/or throat cultures. Patients who are not

penicillin-allergic can receive penicillin VK. A single intramuscular injection of

penicillin G benzathine can be used in patients who are unable to complete a course of

oral antibiotics. It’s important you complete the full course of antibiotics. Oral treatment

course is usually 10 days (Gregori G, Righi O, Risso P, 2016). Choices in patients who

are allergic to penicillins include a macrolide (e.g., erythromycin, azithromycin,

clarithromycin), a cephalosporin (e.g., cephalexin, cefadroxil), or clindamycin. For

patients at risk of reduced compliance, a short course of high-dose azithromycin has

comparable efficacy and bacteriological resolution rates. The treatment for this patient

would be amoxicillin 875 mg BID for 10 days and the doctor may want to schedule a

follow-up visit to ensure that the medication was effective (Altamimi S, Khalil A,

Khalaiwi KA, 2014).

Surgery to remove the tonsils is called a tonsillectomy. This was once a very

common procedure. However, tonsillectomies today are only recommended for people

who experience chronic or recurrent tonsillitis. Surgery is also recommend to treat

tonsillitis that doesn’t respond to other treatment, or tonsillitis that causes complications.
ACUTE TONSILLITIS CASE STUDY

If a person becomes dehydrated due to tonsillitis, they may need intravenous fluids. Pain

medicines to relieve the sore throat can also help while the throat is healing (Burton MJ,

Glasziou PP, Chong LY, 2014).

5. Discharge/education

Home care tips to ease a sore throat and symptoms

 drink plenty of fluids

 get lots of rest

 gargle with warm salt water several times a day

 use throat lozenges

 use a humidifier to moisten the air in your home

 avoid smoke

Also, you may want to use over-the-counter (OTC) pain medications, such as

acetaminophen and ibuprofen. Always check with your doctor before giving medications

to the patient. These may include lozenges, oral sprays, gels, and mouthwashes that

soothe the throat and provide some pain relief. Although there is no evidence that these

can reduce the duration of sore throat, many patients find them helpful. If the pain does

not improve after 3 days, if there is fever over 101°F (>38.3°C), if swallowing becomes

so difficult that it is hard to swallow saliva or liquids, or if any difficulty in breathing

develops, the patient must contact his or her doctor. Similarly, the patient must contact
ACUTE TONSILLITIS CASE STUDY

the doctor if there is any one-sided neck or throat swelling(Windfuhr JP, Toepfner N,

Steffen G, 2016) .
ACUTE TONSILLITIS CASE STUDY

References

Altamimi S, Khalil A, Khalaiwi KA, (2014). Short-term late-generation antibiotics

versus longer term penicillin for acute streptococcal pharyngitis in children. Cochrane

Database Syst Rev;(8):CD004872.

Burton MJ, Glasziou PP, Chong LY, (2014). Tonsillectomy or adenotonsillectomy

versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst

Rev.;(11):CD001802

Gahleitner C, Hofauer B, Stark T, (2016). Predisposing factors and management of

complications in acute tonsillitis. Acta Otolaryngol. Sep;136(9):964-8.

Gregori G, Righi O, Risso P, (2016). Reduction of group A beta-hemolytic

streptococcus pharyngo-tonsillar infections associated with use of the oral probiotic

Streptococcus salivarius K12: a retrospective observational study. Ther Clin Risk

Manag;12:87-92.

Windfuhr JP, Toepfner N, Steffen G, (2016). Clinical practice guideline: tonsillitis I.

Diagnostics and nonsurgical management. Eur Arch Otorhinolaryngol. Apr;273(4):973-8