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November 2015: Throat

A 25-year-old floorhand reported to the medic with a complaint of painful swallowing.  He stated that he first noticed the pain about 6 days prior while eating some soup.  The pain has slowly increased and he has had difficulty swallowing for the last 2 days.  He also has some associated neck soreness, nausea without vomiting, and body aches with subjective fever.

On review of systems he denies chest pain, shortness of breath, dizziness, headache, vision changes, or rashes. He is on day 4/21 of his hitch.

  • Past History: Diabetes (NIDDM), Infectious Mononucleosis
  • Past Surgical History: Appendectomy, vasectomy
  • Current Medications: Metformin (Glucophage) 500 mg bid
  • Immunization Status: Tetanus and Influenza are up to date
  • Social History: Social drinker, smokes 3 packs per day for 3 years
  • Family History: Mother with diabetes, father with high blood pressure

Vitals

  • Temp: 101.9
  • Pulse: 115
  • Respirations: 18
  • Blood pressure: 125/78
  • Pulse Ox: 96% RA

Physical Exam

  • General: Alert and Oriented x 4, no acute distress, sick appearing male
  • HEENT: AT/NC, eyes anicteric, TMs clear, nose clear, nares with dried yellow mucus
  • OP/OC: tonsils appear erythematous with purulent discharge, mucus membranes are moist, postnasal drip appreciated in posterior pharynx
  • Cardio: Regular rhythm tachycardic, no murmurs appreciated
  • Lung: Clear to auscultation bilaterally
  • Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no organomegaly
  • Back: no CVA tednerness
  • Extremities: No clubbing, cyanosis or edema
Throat Image
Photo Source: RemoteMD

Lab Work

  • Rapid strep throat swab: positive for group A streptococcus

How would you approach this patient?

Differential Diagnosis

  • Streptococcal group A pharyngitis
  • Infectious mononucleosis
  • Gonococcal pharyngitis
  • Influenza
  • Human Immunodeficiency Virus
  • Herpes Simplex Virus

Diagnosis: Streptococcal Pharyngitis

Treatment:

  • Penicillin V 500 mg orally three times daily for 10 days, OR
  • Benzathine penicillin G 1.2 million units intramuscular once
  • Alternative treatment for patients that are penicillin allergic include cehalosporins such as cefuroxime, cefpodoxime, cefdinir or macrolides such as azithromycin, clarithromycin or erythromycin
  • Clear, cold liquids to start then advance diet as tolerated
  • Isolation from the remainder of the crew until the patient is 24 hours afebrile
  • Acetaminophen or ibuprofen as needed for discomfort and/or fever
  • Salt water gargle as needed

Patient received the intramuscular injection of benzathine penicillin G and observed in sickbay for 30 minutes to ensure no immediate adverse reaction.  He was then placed in isolation away from the rest of the crew with instructions to hydrate well, and use saltwater gargles as needed for his discomfort.

Discussion:

Group A streptococcal pharyngitis is fairly easy to treat with antibiotics.  If the patient declines the intramuscular injection, it is important to have the patient take the penicillin or equivalent for at least 7 days, preferably 10 days, in order to avoid complications including rheumatic fever, or glomerulonephritis.  The patient should be closely monitored for clinical improvement.  Peritonsilar abscess and mastoiditis are further complication of pharyngitis that may require evaluation by a higher level of care.

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