Sore Throat

Sore Throat

• Physical Exam:
• • – VS: State (or WNL or WNL except…)
  • – General: Patient is in no acute distress
  • – HEENT exam → examine nose, mouth, throat, lymphnodes, check for sinus tenderness → oral thrush, tonsillar exuddate and lymphadenopathy – Nose, mouth, and pharynx wnl
  • – Neck: Supple, No lymphadenopathy
  • – Chest Exam: Auscultation => Clear breath sounds bilaterally/Clear breath sounds bilaterally
  • – Heart Exam: Auscultation => RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard
  • – Abdomen Exam: Auscultation, Palpation, Percussion => Soft, nondistended, nontender, +BS, no hepatosplenomegaly
  • – Skin/Lymph Node Exam: Inspect for rashes, lesions, lymphadenopathy => No rash or lymphadenopathy
• DDX:
  • – Infectious mononucleosis
    
  • – Pharyngitis (bacterial (strep) or viral)
    
  • – Acute HIV infection
    
  • – Streptococcal tonsillitis/scarlet fever
    
  • – Atypical Pneumonia (Mycoplasma pneumonia)
• Work-up:
  • – CBC with diff, peripheral smear
    
  • – Monospot test (Heterophile antibody test for EBV)
    
  • – Rapid Strep Test – Rapid Streptococcal Antigen
    
  • – Throat Culture/ Throat Swab Culture
    
  • – LFTs – AST/ALT/Bili/ALP
    
  • – HIV antibody/Viral Load

HIV, Acute Retroviral Syndrome

• Presentation:
  • sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles.
• DDX:
  • – HIV, Acute Retroviral Syndrome
  • – Infectious Mononucleosis
  • – Hepatitis
  • – Viral Pharyngitis
  • – Streptococcal Tonsillitis/ Scarlet Fever
  • – Secondary syphilis
• Work-up:
  • – CBC, peripheral smear
  • – Monospot test
  • – AST/ALT/bilirubin/alkaline phosphatase
  • – HIV antibody and viral load, CD4 count
  • – Throat culture
  • – Anti-EBV antibodies
  • – VDRL/RPR

Infectious Mononucleosis

• Presentation:
  • sore throat, fever, severe fatigue, and loss of appetite for the past week. reports epigastric and LUQ discomfort. has cervical lymphadenopathy and a rash. partner recently experienced similar symptoms.
  • – MC in adolescents and young adults
  • – Sx = Teen w/ fever, sore throat, muscle soreness, malaise, and fatigue.
  • → Central sx = Fatigue, Malaise, Appetite loss, Headache
  • → Visual sx = Photophobia
  • → Tonsils sx = Erythema, Swelling, White patches
  • → Throat sx = Erythema and Soreness
  • → Lymph nodes sx = Swelling
  • → Respiratory sx = Cough
  • → Spleen sx = Enlargement, LUQ Abdominal pain
  • → Gastric sx = Nausea
  • → Systemic sx = Chills, Fever, and Aches
  • – ~90% of people will acquire EBV no symptoms
  • – Mononucleosis is usually caused by the Epstein-Barr virus (EBV), which infects B cells (B-lymphocytes), producing a reactive lymphocytosis and atypical T cells (T-lymphocytes) known as Downey bodies.
• DDX:
  • – Infectious Mononucleosis*
    – Hepatitis
    – Viral or Bacterial Pharyngitis
    – Acute HIV Infection
    – Secondary Syphilis
• Work-up:
  • – CBC, peripheral smear
    • more white blood cells (lymphocytes) than normal
    • atypical lymphocytes
    • fewer than normal neutrophils or platelets
  • – Monospot test
  • – AST/ALT/bilirubin/alkaline phosphatase
    • abnormal liver function
  • – Throat culture
  • – HIV antibody and viral load
  • – Anti-EBV antibodies VDRL/RPR
• Treatment:
  • Self Care
    • Throat lozenge, Activity restriction, and Bed rest
  • Supportive Care
    • Fluid replacement
  • Medication
    • NSAID – Ibuprofen
    • Analegesic – Acetominophen

Laryngitis

• Presentation:
  • – inflammation in the larynx, or voice box.
  • – larynx sits in the front of the throat, above the windpipe, and it contains the vocal cords.
  • – Inflammation of the vocal cords cause hoarseness of the voice, and some lose their voice temporarily.
  • – caused by
    • yelling or overusing their voice
    •  allergies
    • stomach acid from acid reflux
    • viral infections
    • bacterial infections
• Treatment:
  • Self Care
    • Resting the voice and Throat lozenge
  • Medication
    • Antacid – Calcium carbonate
    • NSAID – Ibuprofen
    • Analgesic – Acetaminophen

Pharyngitis (bacterial or viral)

• Presentation:
  • – fever and sore throat
  • – Painful inflammation of pharynx, and is colloquially referred to as a sore throat.
  • – Infection of the tonsils (tonsillitis) and/or larynx (laryngitis) may occur simultaneously.
  • – ~90% of cases are caused by viral infection, with the rest d/t bacterial infection and, in rare cases, oral thrush (fungal candidiasis e.g. in babies).
  • – Some cases of pharyngitis are caused by irritation from elements such as pollutants or chemical substances.
• Transmission: – Contagious – Respiratory droplets
• DDX:
  • – Pharyngitis (bacterial or viral)
    
  • – Atypical Pneumonia/Mycoplasma Pneumonia
    
  • – Acute HIV infection
    
  • – Infectious Mononucleosis
• Work-up:
  • – Throat swab for culture and rapid streptococcal antigen
    
  • – CBC with diff
    
  • – HIV antibody and viral load, CD4 count
  • – Monospot test
• Treatment:
  • Self Care
    • gargling with warm salt water several times a day (use one half teaspoon or 3 grams of salt in a glass of warm water)
  • Medications
    • Analgesic – Acetaminophen
  •  

Strep Tonsillitis/ Scarlet Fever

• Presentation:
  • – Caused by an exotoxin released by Streptococcus pyogenes Group A
  • – Presentation = sore throat, fever, a ‘strawberry’ tongue, and a fine sandpaper rash over upper (or entire) body
  • – Day 1 = Abrupt onset → Sore throat, reddened fauces, Punctate, bright red rash on hard palate = Coated “strawberry tongue”
  • – Day 2 = Polymorphonuclear leukocytosis. Eosionphiles increased
  • – Day 3 = Flushed cheeks, Punctate blush over neck and chest spreading to entire body. Rash is fine, red, w/ rough-textures, blanches; Pastia lines in armpits and goin, appear (can last after rash gone)
  • – Day 4 = Desquamation (peeling) begins
  • • Scarlet Fever ≠ Rheumatic Fever, but may progress into RF.
• Treatment: 
  • • Penicillin G or Clindamycin to prevent RF (will not prevent post-streptococcal glomerulonephritis)

Tonsillitis

• Presentation:
  • an inflammation of the tonsils.
  • a viral or a bacterial infection.
  • Bacterial tonsillitis – group A Streptococcus bacteria.
  • Symptoms similar to pharyngitis
    • a sore throat
    • red and swollen tonsils
    • white or yellow dots on the tonsils
    • difficulty swallowing
    • abdominal pain
    • a headache
    • stiffness of the neck
• Work-up:
  • Throat Culture
  • Rapid strep test
• Treatment:
  • Self Care – Tea with honey, Salt water gargle, and Throat lozenge
  • Medication: 
    • NSAID – Ibuprofen
    • Analgesic – Acetaminophen
    • Penicillin antibiotic – Amox, Amoxi/Clav, Pen V, Pen G
    • Antibiotics – Chlarithromycin, Clindamycin, Azithromycin, Cephalosporins
  • Surgery – Tonsillectomy – if the condition is long-term or keeps recurring

Throat ulcers

• Presentation:
  • a pus-filled sore that can form on the throat, vocal cords, or food pipe.
    • viral or bacterial infections
    • damage to the tissue lining the throat
    • chemotherapy
    • stomach acid from vomiting or acid refluxCauses:
  • Similar to Pharyngitis
    • difficulty or pain when swallowing
    • white patches in the throat
    • fever
    • chills
    • swollen lymph nodes
    • nausea
• Treatment:
  • Self Care
    •  Gargle with warm salt water or a mixture of salt, water, and baking soda
    • Drink cold fluids or suck on something cold, like ice chips or a popsicle, to soothe the sores.
    • Drink extra fluids