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N21) Fever, sore throat, and dysphagia in a 16-year-old female
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with sore throat and fever.
- Review the DDx considerations in a patient with sore throat and fever.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with sore throat and fever.
History
A 16-year-old female presents to the ED due to a 4 day history of sore throat, decreased appetite, dysphagia, odynophagia, fever, fatigue, and malaise. OTC analgesics and antipyretics have not significantly reduced the symptoms.
Physical Exam
BP: 120/80, HR 105, RR 16, Temp 102F, O2 saturation 95% on room air.
General: Uncomfortable appearing female with muffled speech.
HENT: Bilateral (right greater than left) anterior cervical lymph adenopathy noted. Right tonsillar swelling and erythema with left sided deviation of uvula. Bilateral tonsils with exudates.
Pulmonary: CTAB. No accessory muscle usage.
Labs
Rapid influenza swab: negative. Monospot test: negative. Strep test: pending.
Provisional Diagnosis
Select the Dx you believe is most appropriate
This patient with a severe sore throat, dysphasia, odynophagia, fever, right tonsillar swelling with left sided uvular deviation most likely has a right sided peritonsillar abscess.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
Well done. You were correct
The patient requires urgent workup and management.
First Imaging Study
What is the first imaging study you will order?
A CT neck with IV contrast is the appropriate first imaging modality to confirm diagnosis and assess the extent of the abscess.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
CT neck with IV contrast
On the right side, there is:
The right tonsil is swollen and enhancing, suggesting tonsillitis. The peripherally enhancing peritonsillar lesion with a hypodense center is most consistent with a right-sided peritonsillar abscess.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
No further imaging is required as the diagnosis is strongly suspected on the contrast CT scan.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
The patient’s clinical presentation and imaging findings are consistent with a right peritonsillar abscess.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient requires urgent workup and management to prevent airway obstruction, spread into the deep spaces of the neck, and sepsis.
Assessment and Plan
Please provide your assessment and plan for this patient
This is a 16-year-old female with right-sided peritonsillar abscess causing a severe sore throat, dysphagia, odynophagia, fever, and uvular deviation. She is hemodynamically stable and maintaining her airway. We will administer IV antibiotics, analgesia, and consult otolaryngology for possible incision and drainage or needle aspiration.
Lessons Learned:
- A peritonsillar abscess is a collection of pus between the palatine tonsil and pharyngeal muscles. It is most commonly cause by Group A Streptococcus, occurring as a complication of tonsillitis or peritonsillar cellulitis.
- Patients may present with a sore throat, fever, “hot potato” or muffled voice, trismus, or drooling with uvular deviation to the opposite side.
- Ultrasound or CT can be performed to confirm the presence of an abscess.
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