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Acute Pharyngitis Case Study

1) A 50-year old man presented with a 7 day history of sore throat. He reported associated dyspepsia treated with antacids. 2) Examination found erythematous post pharyngeal wall and tonsillar pillars. Throat culture and endoscopy for GERD were planned. 3) He was diagnosed with acute pharyngitis secondary to GERD. Treatment with proton pump inhibitors for GERD and supportive management for pharyngitis was started. The clinical question regards the improvement in ENT symptoms for GERD patients taking PPIs.

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Hadia Yaqub
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546 views5 pages

Acute Pharyngitis Case Study

1) A 50-year old man presented with a 7 day history of sore throat. He reported associated dyspepsia treated with antacids. 2) Examination found erythematous post pharyngeal wall and tonsillar pillars. Throat culture and endoscopy for GERD were planned. 3) He was diagnosed with acute pharyngitis secondary to GERD. Treatment with proton pump inhibitors for GERD and supportive management for pharyngitis was started. The clinical question regards the improvement in ENT symptoms for GERD patients taking PPIs.

Uploaded by

Hadia Yaqub
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Name: Hadia Yaqub Khan Roll no: 2020-023

Case write-up

HISTORY:
Name: Muhammad Ali Age: 50 yrs
Residence: swat
Married with 3 children
PC: Sore throat since 7 days
HOPC: A 50 year old man with no known co morbid develops sore throat
1 week ago. It was gradual in onset, mild in severity and static.
Associated with dry cough. No aggravating or relieving factors present.
He has been afebrile. No nasal discharge, earache, sneezing, rhinitis,
dysphagia, or hoarseness.
He says that it is associated with dyspepsia and has been taking antacids.
Duration 7 days
Onset sudden
Progression cstatic
Severity 4/10
Treatment none so far except antacids for dyspepsia

Systemic review
ENT - No congestion, changes in hearing, does not wear hearing aids
CVS - No SOB, chest pain, heart palpitations
RES – no shortness of breath, dry cough
Endocrine - No changes in appetite
GIT - No n/v/d or constipation. Dyspepsia (GERD) since 2 years
Genito Urinary - No increased frequency or pain on urination
CNS – no headache, visual disturbances, seizures

Past medical history:


-ve for HTN, DM, CAD, Cancer

Family History:
-ve for HTN, DM, CAD, Cancer

Drug history:
Antacids for dyspepsia

EXAMINATION:
Vitals
Temp 35.9 Pulse 76
RR 20 BP 120/80
Hands
No pallor no jaundice
Eyes
No pallor no jaundice. Eyes reactive to light. EOM intact
Neck
No noticeable or palpable swelling, redness or rash around throat or on
face
Lymph nodes
Not palpable
Legs
No edema
ENT Exam
Oral cavity
Inspection: poor hygiene. Erythematous post pharyngeal wall.
Erythematous tonsillar pillars
IDL: normal vocal cords
Nose
Midline nasal septum. Turbinate’s normal. No finding
Ears
No tenderness. Normal external auditory canal. Normal TM. Cone of
light visible.
Rinnes; +ve B/L
Webers; no lateralization

Investigations
Throat culture
Endoscopy for GERD diagnosis

Diagnosis
Acute pharyngitis secondary to GERD
Management
Proton pump inhibitors for GERD
Supportive management for pharyngitis
Problem Subjective Objective Analysis Plan question
list

biological Sore Alert Acute Throat culture, Improvement


throat for attentive pharyngitis of ENT
Endoscopy for
7 days in no Secondary symptoms in
GERD
visible to GERD patients of
distress GERD by
taking PPI?
Management
Oral cavity Proton pump
Inhibitors
Inspection:
poor Supportive
hygiene. management
Erythemat
ous post
pharyngeal
wall.
Erythemat
ous
tonsillar
pillars
IDL:
normal
vocal cords
Nose
Midline
nasal
septum.
Turbinate’
s normal.
No finding
Ears
No
tenderness
. Normal
external
auditory
canal.
Normal
TM. Cone
of light
visible.
Rinnes;
+ve B/L
Webers;
no
lateralizati
on

social unremarka
ble

Clinical question
Type of question: Therapeutic
What is the improvement in ENT symptoms of GERD patients after
taking PPI?
Patient with GERD related pharyngitis
Intervention none
Comparison GERD patients with ENT symptoms, not taking PPI
Outcome Marked improvement in ENT symptoms by GERD management
with PPI’s

Evidence Article

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