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Tonsillitis

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

 

Doctor Instruction:


You are a doctor working in the emergency department. Your next patient is Dobby Potter, a 21-year-old gentleman presenting with a sore throat. Please take a history and perform an appropriate examination.



 

Patient History:


Your name is Dobby Potter - a 21-year-old student.


You noticed three days ago that your throat has suddenly been sorer than usual and is worsening. The pain is at the back of your throat and is sharp and intermittent. Pain sometimes radiates to the right ear. It affects how you eat food as you feel pain when swallowing food + liquid. Because of this, you have a very poor appetite – you haven't eaten or drunk anything since yesterday! You feel quite nauseous and sick but haven't vomited so far. You have tried ibuprofen which helped to settle the pain a little. You currently rate the pain as 7/10.


You feel tired all the time. You also shivered – you are unsure if you have a fever or not as you haven't taken a temperature. You feel like your voice has become a little husky/ croaky. You have some mild headaches, but this is no concern for you. No cough. No flu-like symptoms. No breathing difficulties. No sinus problems.


Ideas, Concerns, Expectations:

  • You think you have an infection – maybe tonsilitis, but you know they usually settle (you usually have around 3-4 episodes of tonsillitis/ year, which all settled by itself), but in this case, it hasn't. Your new girlfriend also has a sore throat – you think the infection has passed from your girlfriend. You are worried about how this will affect your singing as you have a singing competition at university next month. You want to find out what is going on and resolve your pain.


Past Medical History:

  • No previous history of rheumatic fever.

  • Recurrent tonsillitis 3-4 times/year.


Drug History:

  • Nil

  • NKDA


Family History:

  • Sinus problems from mother – but you do not know much otherwise.


Social History:

  • You live at university accommodation with some mates.

  • You started smoking cigarettes a few months ago – only 1-2 cigarettes/ day.

  • Drink around 1-2 pints of lager every week.

  • You are currently a student studying for a master’s in finance.


 

Examination Findings:

  • Small white patches of pustular exudates on the right tonsil which is inflamed, erythematous, and enlarged

  • The pharynx looks erythematous

  • Right-sided anterior cervical lymphadenopathy on neck palpation.

  • Warm peripheries.

  • Signs of dehydration e.g. reduced skin turgor, prolonged capillary refill time, dry mouth


 

Differentials:

  1. Tonsilitis (Likely Bacterial > Viral)

  2. Pharyngitis +/- gonococcal

  3. Laryngitis

  4. Infectious mononucleosis (glandular fever)

  5. Quinsy


 

Investigations:


Bedside:

  • Clinical Diagnosis

  • Observations (pyrexia)

  • Consider throat culture swab/ rapid streptococcal antigen test


Bloods:

  • Consider routine bloods test if systemically unwell (FBC, CRP, LFT, U&Es, Bone profile) + blood culture

  • Consider Paul-Bunnell blood test / Heterophile antibody testing (EBV/ glandular fever)

  • Consider HIV if recurrent / severe infection / suspected immunodeficiency

  • Consider vaginal, cervical or penile, and rectal culture in suspected gonococcal pharyngitis


 

Management:

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