Case Presentation by Katherine Shulman, MD
Chief Complaint: Difficulty swallowing
History of Present Illness: This is a 66-year-old male with no significant medical history who comes in to emergency department complaining of difficulty in swallowing beginning 3 months ago. He further describes it as a foreign body sensation in his throat and has started eating a soft diet, which he tolerates well. He reports only mild discomfort with swallowing. Also, three months ago he noticed a change in his voice. He reports a “very mild” baseline shortness of breath over the same timeframe. He denies any neck pain, chest pain, fevers, night sweats, or headaches. No recent dental procedures. Denies any URI symptoms in the past several months.
Past Medical History: none
Social History: Denies tobacco, alcohol, or illicit drug use.
Family History: His brother just died of laryngeal cancer two months ago.
Vital Signs: BP 145/82; HR 98; RR 16; Temp 36.8; 98% RA
General: Patient sitting semi-fowler in stretcher in no acute apparent distress, with no acute respiratory distress. Handling oral secretions well. Speaking in full sentences with a muffled voice. Resting comfortably.
Head: normocepahlic; atraumatic
Eyes: EOMI; PERRL; pink conjunctiva
Mouth: moist mucous membranes, no tongue or submandiblar swelling, good overall dental hygiene, uvula midline; significant area of swelling in the right oropharynx just posterior to the tonsil with normal appearing overlying mucosa; no erythema, exudates, ulcerations in the anterior or posterior pharynx.
Neck: Supple; trachea midline; no palpable lymphadenopathy
Cardiovascular: s1, s2; regular rate and rhythm; no murmur
Respiratory: no stridor, lungs clear to auscultation bilaterally; symmetrical chest rise and fall; no accessory muscle use
Workup: We obtained laboratory tests and a CT – Neck w/ contrast.
- What is the most likely diagnosis?
- Peritonsillar Abscess
- Nasopharyngeal Carcinoma
- Ludwig’s Angina
- What is the most likely causative organism?
- Streptococcus Species
- Staphylococcus Aureus
- Haemophilus Influenzae
- What are the next steps in management?
- Initial dose IV Clindamycin, discharge home w/ PO Clindamycin, and ENT f/u
- IV Unasyn, consult ENT, medicine admit
- IV Zosyn, consult ENT, ICU admit for compromised airway
- Consult ENT, obtain blood cultures, medicine admit
Filed under: Senior Report