INTERNAL MEDICINE

CASE PRESENTATION
By: Joyce Dianne T. Jose
Date & Time collected: July 16, 2019, 4:10 pm
Informant: Patient
Reliability: 90%
GENERAL DATA
S.G., 27 years old, female, Filipino, Born Again
Christian, single, Social worker, born on October 18,
1991 in Mandaue City, currently residing in Mandaue
City, was admitted at CDUH on July 15, 2019 for the
first time
CHIEF COMPLAINT

Dysphagia
HISTORY OF PRESENT ILLNESS
3 weeks PTA, patient had odynophagia with pain score of
5/10. Pain is aggravated by ingestion of dry and solid foods.
No medication was taken to relieve the pain. This was
accompanied by a fever of Tmax 37.6°C, chills, and body
malaise. She self-medicated with Paracetamol(Biogesic)
500mg taken every 4 hours but with no reported relief. A total
of 2 tablets were taken. She then sought consult at a clinic, to
which she was prescribed with Cefuroxime(Zegen) 250mg to
be taken twice a day for 5 days.
HISTORY OF PRESENT ILLNESS
She was mostly compliant, however on the 4th day, she had a
vaginal irritation to which she attributed to the medication and
thus discontinuing the course of her antibiotic therapy. She
claimed that all the symptoms subsided after her short-course
of antibiotics. No cough, no colds, no change in appetite noted.
HISTORY OF PRESENT ILLNESS
2 weeks PTA, odynophagia recurred still with pain score of 5/10.
Fever also recurred with Tmax 38 °C, to which she took
Paracetamol 500mg once and reported no decrease in
temperature. This was also accompanied by nocturnal dyspnea
and snoring, both relieved by elevating the head of the bed.
She sought consult at a private clinic. She was also prescribed with
Amoxicillin 500mg twice a day for 10 days. Patient was compliant
with medications. Fever reportedly subsided, and reported only
slight relief of odynophagia. No follow-up consultation done.
HISTORY OF PRESENT ILLNESS
Patient was able to continue with activities of daily living. No
reported change in appetite despite sore throat, and no
changes in sleep pattern.
HISTORY OF PRESENT ILLNESS
1 day PTA, odynophagia still persistent and of the same
character. She reported a hoarseness to her voice. No relief
measures were attempted and no aggravating factors.

1 hr PTA, fever once again recurred of Tmax 38.2 °C and left

cervical lymph node tenderness was reported. Odynophagia
was still persistent. However, it was now accompanied by
dysphagia, causing a decrease in her appetite, which
prompted her to seek consult at CDUH OPD. Upon close
inspection by the attending physician, she was then advised for
admission due to bilaterally enlarged tonsils covered with
patchy white exudates.
PAST MEDICAL HISTORY
Pt. reported to have received the following
childhood immunizations at Barangay Opao Health
Center: BCG- 1dose at birth, Hep B-3 doses, DPT-3
doses, OPV-3 doses and MMR-2 doses. No history of
measles, mumps, and chickenpox.
PAST MEDICAL HISTORY
In 2016, she received 3 doses of Hep B booster vaccines with
appropriate interval between doses, as compliance with work
policies. No adult illnesses such as hypertension, diabetes and
asthma. No previous hospitalizations, surgeries, accidents nor
injuries. No known food and drug allergies. No screening tests
done.
OB History: Menarche was at 16 years old, lasting up to 5 days,
with moderate flow, would use 2 pads/day. Subsequent menses
were regular, lasting 5 days, moderate flow, usually can use 3
pads/day, and interval between menses is 30 days. No
dysmenorrhea experienced.
No sexual history.
PERSONAL/ SOCIAL HISTORY
Patient has a Bachelor’s degree in Tourism, and is now working as a
Social Worker mostly dealing with childcare. Her hobbies include
going out with friends, food trips, and sometimes helping out at their
church. She drinks only on special occasions and has no history of
tobacco smoking. She has good sleeping habits. Her exercise habit
includes walking in a moderate pace for 30 mins, once every week.
She is currently living with her parents, in a owned duplex home
with good water and electric supply and good practice of garbage
disposal and collection.
FAMILY HISTORY
Her mother, 53 years old, a social worker, is currently taking maintenance
medications for:
Anemia (yr diagnosed: unrecalled) – Ferrous Sulfate once a day, before
breakfast
Hyperthyroidism (2015) – Methimazole; (Tapdin) once a day, before
breakfast
Her father, 55 years old, a mission pastor, is currently taking maintenance
medication for:
Hypertension (Jan 2019) – Clopidogrel once a day, noon time
- Amlodipine once a day, in the morning
They are both compliant with their medications.
FAMILY HISTORY
She is the middle child in a family of 3. Her eldest sibling is
male, 29 years old, and the youngest is male 24 years old.
Both are healthy.
Heredofamilial diseases are hypertension on both sides.
Diabetes on the paternal side and hyperthyroidism/goiter
on the maternal side.
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
General Survey
Examined patient on her 2nd hospital day. Patient is conscious, alert,
coherent, cooperative and oriented to time, place, and person. She
is ambulatory and not in respiratory distress. An IV line was inserted
at the left dorsum of her hand
She has a mesomorphic build. Physical appearance appropriate for
age. No involuntary movements, speech impairment.
PHYSICAL EXAMINATION
VITAL SIGNS
BP: 110/80mmHg, right arm, sitting
PR: 80bpm, right radial, regular
RR: 18cpm, regular, normal depth
Temp: 36.7 C, right axilla

ANTHROPOMETRIC MEASUREMENTS
Height: 5ft (1.524m)
Wt: 58.5 kg
BMI: 25.2 (Overweight)
PHYSICAL EXAMINATION
Skin: Fair skin complexion, no signs of jaundice and cyanosis, good mobility
and turgor
Nails: No discoloration, no pitting, no clubbing, CRT = less than 2 seconds
Hair: Black in color, evenly distributed and smooth in texture
Head: normocephalic, no deformities
Face: Facial features are symmetrical. No abnormal facies noted. No lesions
Ears: Both symmetrical, no deformities, cerumen, lesions nor discharge noted.
External auditory canal is pink, intact. Tympanic membranes are pearly,
intact and with normal light reflex. Good auditory acuity.
No tenderness on auricles and tragus
 PHYSICAL EXAMINATION
Eyes:
Visual Acuity: 20/20 OU
External Eye Exam: No orbital rim deformities, no eyelid
retractions, anicteric sclera, non-congested conjunctiva,
positive Hirschberg reflex, no lens opacities, both pupils are
equally reactive to light
EOM: full range of motion, no nystagmus, no diplopia
Tonometry: Both are soft
Fundoscopy: Positive Red Orange Reflex
PHYSICAL EXAMINATION
Nose and Paranasal Sinuses: Symmetrical, nasal turbinates
intact and non-erythematous, nasal septum intact and in the
midline, no maxillary and frontal sinus tenderness
Mouth/Throat: Lips are pink-red. Pink oral mucosa. Dentition
good, (-) bleeding gums. Tongue is pink and in midline, uvula
midline. Pharynx are erythematous and edematous but free of
masses and exudates. Tonsils are bilaterally enlarged – Grade
2, erythematous and covered with white exudates.
PHYSICAL EXAMINATION
Neck: Trachea midline. No masses, scars noted.
Discomfort felt upon turning of head to the left.
Normal pulsations of the carotid artery on both sides.
Thyroid not palpable. Left tonsillar and anterior
cervical lymph nodes are tender and enlarged. Right
tonsillar and cervical lymph nodes are normal.
PHYSICAL EXAMINATION
Breast and Axilla: Both breasts are symmetric, without
lesions, scars, mass, dimpling, nor retractions; no
lymphadenopathy in both axilla
Chest and Lungs: Symmetrical thorax, normal depth
of respiration, no intercostal retractions nor
deformitites. Equal chest expansion, equal tactile
fremitus, lungs resonant, clear breath sounds. Resonant
on all lung fields. Clear breath sounds. No crackles
nor wheezing.
PHYSICAL EXAMINATION

Cardiovascular System: No jugular vein

distention, no cyanosis. PMI at 5th ICS, 7 cm from
MSL, no thrills nor heaves. Left cardiac borders
within normal range, no dullness beyond Right
edge of sternum in 3rd-5th ICS. Distinct S1 and S2,
Regular rhythm, (-)murmurs and extra heart
sounds
PHYSICAL EXAMINATION
Abdomen: Protuberant, round, symmetrical. No scars, striae, hernia,
masses, nor lesions noted. NABS-10clicks/min, Spleen is normal with
usual dullness noted. Liver span-8cm in right midclavicular line.
tympanitic, non-tender on all quadrants, (-) Psoas, Rovsing, and
Murphy’s sign
Back and extremities: Spine - normal curvature, all joints in full
range of motion, no pain on flexion and extension, no deformities
PHYSICAL EXAMINATION
Neurologic Exam:
Mental Status: Patient is alert and cooperative, appropriate
thought process and speech
Cranial Nerves:
CN I: able to distinguish smell of coffee
CN II: Visual acuity: 20/20, visual fields are normal
CN II/III: (+) direct and consensual light reflex
CN III, CN IV, CN VI: EOM full range of motion for both eyes
CN V: Able to clench teeth, perceive pain, light touch, hot
and cold temp., positive corneal reflex(CN V/VII)
CN VII: Able to smile, raise eyebrows, and close eyes, no
facial asymmetry
PHYSICAL EXAMINATION
 CN VIII: Normal on whispered voice test. no lateralization, AC>BC
 CN IX and CN X: Voice is hoarse, uvula intact and midline. Gag reflex not
assessed.
 CN XI: Able to shrug both shoulders. Able to turn head against resistance but
discomfort felt upon turning of the head to the left.
 CN XII: Tongue is in the midline and without fasciculation
Motor System: No atrophy of extremities, (-) Pronator drift test,(-) Romberg’s
test
Coordination: No dysdiadochokinesia, no dysmetria
Sensory System: Able to sense pain, touch, temperature and vibration
Reflexes: +2 all throughout
Muscle strength: 5/5 on proximal and distal extremities
 SUMMARY OF IMPORTANT FINDINGS
S.G., 27 years old, female, single
Chief complaint: Dysphagia
3 weeks PTA: odynophagia, fever, chills, body malaise. Was prescribed with
Cefuroxime(Zegen) 250mg, twice a day for 5 days. 4th day of antibiotics,
had a vaginal irritation to which she attributed to the medication and thus
stopped taking it.
2 weeks PTA: recurrence of odynophagia and fever. Nocturnal dyspnea and
snoring. Prescribed with Amoxicillin 500mg twice a day for 10 days.
1 day PTA: odynophagia persistent, voice hoarseness
1 hr PTA: fever recurred, odynophagia persistent, left cervical lymph node
tenderness, dysphagia , decreased appetite, bilaterally enlarged tonsils
covered with white exudates.
 SUMMARY OF IMPORTANT FINDINGS
Pharynx are erythematous and edematous but free of masses
and exudates.
Tonsils are bilaterally enlarged – Grade 2, erythematous and
covered with white exudates
Neck discomfort upon turning of head
(-) cough, (-) colds, (-)nausea, (-)vomiting, (-) drooling
 LOGICAL IMPRESSION
Streptococcal Tonsillopharyngitis
1. Fever
2. (-) Cough
3. Pharynx are erythematous and edematous but free of
masses and exudates. Tonsils are bilaterally enlarged –
Grade 2, erythematous and covered with white patchy
exudates
4. Enlarged anterior cervical lymph nodes
Streptococcal Tonsillopharyngitis
-Caused by Streptococcus Pyogenes (Grp A β-hemolytic)
-Infection is acquired through contact with another individual
carrying the organism.
-Respiratory droplets are the usual mechanism of spread. Other
route: food-borne outbreaks
-Incubation period is 1–4 days.
GRP A STREPTOCOCCAL PHARYNGITIS

Regional adherence to
pharyngeal epithelial cells

Releases exotoxins

SPE

Release of Stimulates
cytokines mononuclear
cells

Erythema
Fever,
Pharyngeal Edema,
Enlarged tender
anterior cervical nodes,
Pharyngeal Exudates
 DIFFERENTIAL DIAGNOSIS
Rule In
Infectious Mononucleosis fever, malaise, sore throat,
symptoms lasting 1-2 weeks
Retropharyngeal Abscess Odynophagia and dysphagia,
diffuse erythema of pharynx,
exudate on tonsils, voice
hoarseness, neck discomfort,
cervical adenopathy
Acute Primary HIV Infection fever, sore throat,
lymphadenopathy, malaise
Rule Out
No generalized
lymphadenopathy,
No splenomegaly and
hepatomegaly
No history of cough, no trismus,
no drooling
More common in 2-4 years old
No nonpruritic maculopapular
rash
No myalgia and arthralgia
No RF for HIV (no sexual activity)
 DIAGNOSTIC MANAGEMENT
1. History and Physical Exam
2. CBC
3. Throat Swab Culture/Rapid Antigen Detection Test
4. Viral Culture/ELISA
5. HIV RNA or Antigen Testing
6. Lateral Neck Radiography
 THERAPEUTIC MANAGEMENT
Antibiotic Therapy – Penicillin G 1.2 million units IM × 1, or
penicillin V (250 mg PO tid or 500 mg PO bid) × 10 days
Maintain hydration status by IV fluid therapy and adequate fluid
intake
Oral rinses to ease throat discomfort
Advise patient to rest
Recommend a soft diet until appetite returns to normal
Provide health teaching on maintaining good oral hygiene
Provide health teaching on hand hygiene, to prevent spread of
microorganisms
 REFERENCES
Harrison’s Principles of Internal Medicine, 19th edition