19. Sore throat

Question 1

sore throat medical term

Answer 1

pharyngitis - inflammation of naso oro or hyopharynx

Question 2

Nasopharynx area parts

Answer 2

superior to oral cavity from skull base to soft palate
includes opening eustachian tubes

Question 3

Oropharynx parts

Answer 3

area immed visible when pt opens mouth - uvula, hyoid, tonsillar pillars
includes vallecula and epiglottis

Question 4

Hypopharynx parts

Answer 4

inferior to epiglottis and terminates at vocal cords

Question 5

Pharyngeal tonsillar ring: which lymph tissues are present?

Answer 5

pharyngeal (adenoid), tubal, palatine, and lingual tonsils

Question 6

Key signs and symptoms in sore throat

Answer 6

airway assessment
- drooling, muffled voice, neck swelling, stridor

hydration/overall toxicity

Question 7

Name 8 critical diagnosis of sore throat

Answer 7

Trauma causing an expanding neck hematoma
Epiglottitis causing airway compromise
Retropharyngeal or parapharyngeal abscess causing airway compromise Peritonsillar abscess causing airway compromise
Ludwig angina
Angioedema
Croup causing stridor at rest
Lemierre syndrome from septic internal jugular thrombophlebitis
Acute coronary syndrome presenting with referred throat pain

Question 8

Emergent dx of sore throat

Answer 8

Trauma causing a nonexpanding neck hematoma
Mass lesion in the neck causing sore throat (tongue, larynx, thyroid, leukemia)
Epiglottitis, retropharyngeal, parapharyngeal, or peritonsillar abscess not
causing airway compromise Stevens-Johnson syndrome

Question 9

Urgent sore throat diagnoses

Answer 9

Group A streptococcal pharyngitis Retained foreign body
Kawasaki disease
Thyroiditis
Laryngeal fracture
Pericarditis or myocarditis presenting with referred throat pain

Question 10

Modified centor criteria/McIsaac score parts

Answer 10

of Criteria Present

fever >38
tonsilar excdate
tensor cervical ln
no cough
age 3-14y is one oint vs age >45 -1

Question 11

Modified centor criteria/McIsaac score likelihood of group a beta hemolytic strep if 1 present (percent)

Answer 11

7%

Question 12

Modified centor criteria/McIsaac score likelihood of group a beta hemolytic strep if 2 present (percent)

Answer 12

13%

Question 13

Modified centor criteria/McIsaac score likelihood of group a beta hemolytic strep if 3 present (percent)

Answer 13

22%

Question 14

Modified centor criteria/McIsaac score likelihood of group a beta hemolytic strep if 4 present (percent)

Answer 14

38%

Question 15

Modified centor criteria/McIsaac score likelihood of group a beta hemolytic strep if 5 present (percent)

Answer 15

> 50%

Question 16

4 original centor score criteria

Answer 16

fever
no cough
cervical LN
tonsilar exudate

Question 17

What makes a viral pharngitis more likely on exam?

Answer 17

rhinorrhea
hoarse
sneeze
cough
conjunctivits

Question 18

DDX infectious strep - name 5 viruses

Answer 18

rhino
adeno
corona
influ a or b
hsv 1,2
cmv
ebv
vzv
hepatitis

Question 19

DDX infectious strep - name 5 aerobic bacteria

Answer 19

gas
coccidiodies
non gas
neisseria gonorrhea or meningitides
mycoplasma pneum
arcanobacterium haemolyticum
chlamydia trachmoatis
staph aures

Question 20

Name 5 uncommon bacteria causing pharyngitis

Answer 20

h influ
h parainflu
cornyebacterium diptherae
yersinea
treponema
francisella tularensis
legionella
mycobacterium

Question 21

DDX infectious strep - name 5 anaerobic bacteria

Answer 21

bacteroides
peptococcus
clostridium
prevotella
fusobacterium
peptostreptococcus

Question 22

DDX infectious strep - name 1 fungal

Answer 22

candida

Question 23

what is lemierre syndrome

Answer 23

septic thrombophlebitis, can complicate an episode of acute pharyngitis or a peritonsillar abscess, and affects the ipsilateral internal jugular vein.

Question 24

Ancillary testing for GAS

Answer 24

rapid antigen test only centor >2 and if child >3 with negative rapid, do culture

if adult with centor >/=3 can do rapid test

consider monospit

Question 25

Thumb sign in what disease on XR?

Answer 25

epiglottis

Question 26

Tx viral pharyngitis

Answer 26

nsaid or tyl supportive

Question 27

Name 5 red flags associated with airway compromise in sore throat

Answer 27

stridor drool muffled voice sniffing position hypoxia

Question 28

Visible mass with signs of airway compromise in sore throat - who to call?

Answer 28

ent

Question 29

Airway management in sore throat with impending compromise

Answer 29

consider double set up - ent, anesth, surg upright iv o2 monitor empiric steroids/abx to consider

Question 30

In patients who test + for GAS by rapid test, naat or culture, what to tx?

Answer 30

IM pen G or 10 course oral pen VK

Question 31

Tx of epiglottis - abx?

Answer 31

predominantly caused by Streptococcus, Staphylococcus, and nontypeable Haemophilus species, and we recommend parenteral treat- ment with ceftriaxone (50 mg/kg or 1000 mg qd), ampicillin/sulbactam (50 mg/kg of ampicillin component or 3000 mg q6h), or levofloxacin (750 mg qd) in penicillin-allergic patients

Question 32

Tx RPA/PTA and Ludwig angina -abx

Answer 32

ampicillin/sulbactam (50 mg/kg or 3000 mg q6h of penicillin G (4 million units or 50,000 units/kg qid) and met- ronidazole (500 mg or 7.5 mg/kg qid), until culture results are avail- able.

Question 33

Tx Lemierre disease- abx

Answer 33

piperacillin/ tazobactam (3.375 gm qid) or the combination of ceftriaxone 1000 mg q24h and metronidazole 500 mg q8h.

Question 34

Name 4 different possible tx regimens for GAS

Answer 34

Benzathine penicillin G, intramuscular, 600,000 U for <27 kg and 1.2 million U for >27 kg Penicillin V, oral, children <27 kg 250 mg 2 to 3 times daily; children ≥27 kg 500 mg 2 times daily; adolescents and adults 250 mg 4 times daily or 500 mg twice daily × 10 days Amoxicillin, oral, 50 mg/kg once daily (max = 1000 mg); or 25 mg/kg (max = 500 mg) twice daily × 10 days If penicillin-allergic: Clindamycin, oral, 7 mg/kg/dose 3 times daily (maximum, 300 mg/dose) × 10 days Cephalexin, oral, 20 mg/kg/dose twice daily (maximum, 500 mg/dose) × 10 days Azithromycin, oral, 12 mg/kg/day × 5 days

Question 35

A 20-year-old female presents to the emergency department com- plaining of a sore throat. She has a temperature of 39°C, tender cer- vical lymphadenopathy, exudates on exam and denies any history of cough, rhinorrhea, nausea, vomiting or diarrhea. Her modified Centor score is which of the following? a. 2 b. 3 c. 4 d. 5

Answer 35

c

Question 36

24-year-old female presents for sore throat, difficulty swallowing, and a muffled voice. On examination, she has fullness, swelling and induration of the left posterior peritonsillar area with uvular devi- ation to the right. What is the next step in the management of this patient? a. Computed tomography imaging b. Discharge with antibiotics, clindamycin 300 mg TID × 10 days c. Drainage either by needle aspiration or incision and drainage d. Rapid Antigen Detection Test for Group A Streptococcus

Answer 36

c

Question 37

A 39-year-old male presents to the emergency department com- plaining of a sore throat. He is sitting forward on the stretcher, drooling, with inspiratory stridor. His oropharynx exam shows minimal erythema and no exudate. Which of the following condi- tions is the likely diagnosis? a. Epiglottitis b. Group A streptococcal pharyngitis c. Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome d. Viral pharyngitis

Answer 37

a

Question 38

In adult patients who test positive for Group A streptococcal (GAS) pharyngitis who have no allergies, which of the following is the most appropriate antibiotic choice? a. Azithromycin 12 mg/kg/day (max dose, 500 mg) × 5 days b. Clindamycin 7 mg/kg/dose (max dose, 300 mg) TID × 10 days c. Metronidazole 30 mg/kg/day divided TID × 10 days d. Penicillin VK 50 mg/kg/day divided QID × 10 days

Answer 38

d

Question 39

In which age group is Group A streptococcal infection most com- mon? a. Age <3 years b. Age 5–15 years c. Age 15–45 years d. Age >45 years

Answer 39

b