morning report

CC: "Sore throat, cough'

• 2 wk, progressively worsening sore throat, cough
• Worse w/ swallowing, eating
• Subjective fevers x 2wk
• Dry cough, "always spitting phlegm"
• Pert Neg - n/v, d/c, SOB, c/p, night sweats

CC: "Sore throat, cough'

• Allergies - none
• Meds - HAART (prophylaxis)
• PMH/PSH - none
• SH - social drinker/ smoker, MSM (1)
• VS - 100.1, 89, 121/81, 19 (99%RA)

DDX

• Viral, strep pharyngitis
• Retropharyngeal abscess
• Peritonsillar abscess
• Tonsillar cellulitis
• Epiglottis
• Ludwigs Angina
• Misc - Malignancy, referred pain (ACS), FBA

Physical EXAM

• VS - 100.1, 89, 121/81, 19 (99%RA)
• Gen - anxious, spitting in cup, "nasally", muffled voice
• Oral - uvula deviation, u/l tonsillar swelling
• Lungs - CTABL
• "Nasally", muffled voice

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DDX - PT Abscess vs. cellulitis

WU - PT Abscess vs. cellulitis

• CBC, BMP (though not necessary)
• Throat culture
• CT
• Ultrasound
• *Abscess culture (if drained)

CT-NECK

ULTRASOUND

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peritonsillar Abscess

• Pus between tonsils and superior constrictor muscle
• 90% unilateral
• Polymicrobial, anaerobes, GABS, s.aureus
• Sx - fever/chills, trismus, “hot potato voice”, “worst sore throat of my life”; drool (spit), difficulty swallowing
• RF - immunocompromised, smokers, M>F

Tx - Peritonsillar Abscess

• I/D
• Needle aspiration drainage
• AB's (450mg Clindamycin PO q6h or 875mg Amox/Clauvulanate PO BID)

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PTA drainage STEPS

• Pre-treat - 1mg Ativan
• Numb - Lido w/ epi (5cc syringe, 27G)
• US visualize and measure
• Supply preparation
• Drain

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PTA drainage tips

• VL (held by patient)
• 2-person drainage (IV tubing)
• Cold-water rinse (decr bleeding)

Complications - PTA

• Airway obstruction
• Recurrence (10-15%)
• Carotid Artery Rupture*
• Aspiration PNA/ Bacteremia
• Lemierre's Syndrome (JV thrombophlebitis)

Summary - PTA

• Not all sore throat = strep
• TVUS = quick diagnosis
• Be safe - Measure & cap needle
• VL = great tongue depressor
• Skip the consult (this is why you chose EM)

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