Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

Cabanatuan City, Nueva Ecija, Philippines

CASE ANALYSIS

Submitted By:
Vincent C. Parong
Patrick Turalba

Submitted To:
Girlie DL. Tayao, MAN, RN
Professor
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

I. Definition
Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both. Symptoms may
include sore throat, dysphagia, cervical lymphadenopathy, and fever. Diagnosis is clinical,
supplemented by culture or rapid antigen test. Treatment depends on symptoms and, in the case
of group A beta-hemolytic streptococcus, involves antibiotics.

Tonsillopharyngitis is usually viral, most often caused by the common cold viruses (adenovirus,
rhinovirus, influenza, coronavirus, and respiratory syncytial virus), but occasionally by Epstein-
Barr virus, herpes simplex virus, cytomegalovirus, or HIV.

II. Risk factor

 Commonly infects children aged 5-15 years old and rare in <3 years old
 Parents of school-aged children and other adults who are in close contact with the
infected individual
 Crowded places like day care centers, schools and military barracks

III. Clinical manifestation

Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both. Symptoms may
include sore throat, dysphagia, cervical lymphadenopathy, and fever. Diagnosis is clinical,
supplemented by culture or rapid antigen test. Treatment depends on symptoms and, in the
case of group A beta-hemolytic streptococcus, involves antibiotics.

IV. Signs and Symptoms

Pain with swallowing is the hallmark and is often referred to the ears. Very young children who
are not able to complain of sore throat often refuse to eat. High fever, malaise, headache, and GI
upset are common, as are halitosis and a muffled voice. A rash may also be present. The tonsils
are swollen and red and often have purulent exudates. Tender cervical lymphadenopathy may be
present. Fever, adenopathy, palatal petechiae, and exudates are somewhat more common with
GABHS than with viral tonsillopharyngitis, but there is much overlap. With GABHS, a
scarlatiniform rash (scarlet fever) may be present.
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

V. Pathophysiology
Clinical presentation suggestive of
Chief complaint of sore group A Streptococuss (GAS) infection
throat (sudden fever Pharyngitis,
lyphadenophaty, absence of upper
respiratory infection)
Clinical presentation
suggestive of viral
infection (coryza, caugh,
conjunctivitis, diarrhea)
GAS rapid antigen test

No diagnostic testing
suggested. Supportive GAS rapid GAS rapid
care recommended. detection test: antigen detection
NEGATIVE test: POSITIVE

Send
Start antibiotic
confirmatory
Therapy
throat culture

Throat culture Throat culture

NEGATIVE POSITIVE

No further
testing. Support Start antibiotic
care property
recommended

VI. Nursing management

Follow Up

Follow-up of asymptomatic patients after completion of antibiotic course is not typically

necessary

Follow-up Cultures are Indicated in:

 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

 Patients who remain symptomatic

 Patients whose symptoms recur

 Patients with history of rheumatic fever

Patients who develop acute pharyngitis during outbreaks of either rheumatic fever or post-
streptococcal glomerulonephritis, or during outbreaks of group A beta-hemolytic streptococci
(GABS) pharyngitis in closed or partially closed communities

 Continual spread of infection within a family

 The Following Should be Considered if Recurrent Episodes Occur:

 Persistence of group A streptococcus carriage in the face of an intercurrent viral infection

 New group A streptococcus pharyngeal infection obtained from contacts

 Noncompliance with treatment regimen

 Management of Recurrent Episodes of Acute Pharyngitis

 Single Episode with Laboratory Confirmation Shortly After Completion of Antibiotic Course

 Re-treat with any of the recommended agents for GABS

Agents such as a narrow-spectrum cephalosporin, Clindamycin or Amoxicillin/clavulanic acid, or

the combination of Penicillin and Rifampin, are reasonable in the treatment of patients with
GABS pharyngitis in whom initial Penicillin treatment has failed

Consider intramuscular Benzathine Penicillin if noncompliance is suspected

For Multiple Episodes Over Months or Years

It may be difficult to differentiate viral pharyngitis in a Streptococcus sp carrier from true group
A streptococcal pharyngitis

Assess for transmission within families wherein one family member or close contact may be an
asymptomatic carrier of GABS

It has been shown that vaccination against influenza and pneumococcus may result in
significant reductions in the number of future episodes of acute sore throat
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

Surgical removal of tonsils may be considered for patients whose symptomatic episodes do not
diminish in frequency over time and for whom no alternative explanation for recurrent
pharyngitis is evident

≥7 episodes of tonsillitis over a 12-month period or ≥5 episodes/year in the past 2 years or ≥3

episodes/year in the past 3 years with documentation for each episode of sore throat and ≥1 of
the following:

Temperature >38.3°C (101°F)

Cervical adenopathy

Tonsillar exudate

Positive test for GABS infection

Symptoms interfere with patient’s normal daily function

VII. Drug Therapy

Supportive treatments include analgesia, hydration, and rest. Analgesics may be systemic or
topical. Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually effective systemic
analgesics. Some clinicians also give a single dose of a corticosteroid (eg, dexamethasone 10 mg
IM), which may help shorten symptom duration without affecting rates of relapse or adverse
effects . Topical analgesics are available as lozenges and sprays; ingredients include benzocaine,
phenol, lidocaine, and other substances. These topical analgesics can reduce pain but have to be
used repeatedly and often affect taste. Benzocaine used for pharyngitis has rarely caused
methemoglobinemia.

Penicillin V is usually considered the drug of choice for GABHS tonsillopharyngitis; dose is 250
mg orally 2 times a day for 10 days for patients < 27 kg and 500 mg for those > 27 kg.
Amoxicillin is effective and more palatable if a liquid preparation is required. If adherence is a
concern, a single dose of benzathine penicillin 1.2 million units IM (600,000 units for children ≤
27 kg) is effective. Other oral drugs include macrolides for patients allergic to penicillin, a 1st-
generation cephalosporin, and clindamycin. Diluting over-the-counter hydrogen peroxide with
water in a 1:1 mixture and gargling with it will promote debridement and improve oropharyngeal
hygiene.

VII. Medical and Surgical

Medical management

Throat swab
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

With this simple test, the doctor rubs a sterile swab over the back of your child's throat to get a
sample of secretions. The sample will be checked in the clinic or in a lab for streptococcal
bacteria.

Many clinics are equipped with a lab that can get a test result within a few minutes. However, a
second more reliable test is usually sent out to a lab that can often return results within several
hours or a couple of days.

If the rapid in-clinic test comes back positive, then your child almost certainly has a bacterial
infection. If the test comes back negative, then your child likely has a viral infection. Your
doctor will wait, however, for the more reliable out-of-clinic lab test to determine the cause of
the infection.

Complete blood cell count (CBC)

Your doctor may order a CBC with a small sample of your child's blood. The result of this test,
which can often be completed in a clinic, produces a count of the different types of blood cells.
The profile of what's elevated, what's normal or what's below normal can indicate whether an
infection is more likely caused by a bacterial or viral agent. A CBC is not often needed to
diagnose strep throat. However, if the strep throat lab test is negative, the CBC may be needed to
help determine the cause of tonsillitis.

Surgical Management

Tonsillectomy

Surgery to remove tonsils (tonsillectomy) may be used to treat frequently recurring tonsillitis,
chronic tonsillitis or bacterial tonsillitis that doesn't respond to antibiotic treatment. Frequent
tonsillitis is generally defined as:

 At least seven episodes in the preceding year

 At least five episodes a year in the past two years
 At least three episodes a year in the past three years
 A tonsillectomy may also be performed if tonsillitis results in difficult-to-manage
complications, such as:

Obstructive sleep apnea

Breathing difficulty
Swallowing difficulty, especially meats and other chunky foods.An abscess that doesn't improve
with antibiotic treatment. A tonsillectomy is usually done as an outpatient procedure, unless your
child is very young, has a complex medical condition or if complications arise during surgery.
That means your child should be able to go home the day of the surgery. A complete recovery
usually takes seven to 14 days.
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

ASSESSMENT NURSING OUTCOME PLANNING NURSING EVALUATION

DIAGNOSIS IDENTIFICATION INTERVENTIO
N
Objective: Impaired oral After 5 hours of Improve the -Advice mother After 5 hours
-Reddened tonsils - mucous nursing patient's condition to continue with of nursing
Vital signs taken as membrane intervention, and recurrence of the antibiotics as intervention,
follows: related to patient's mother the infection will prescribed by the patient's mother
T=37.3 infectious will verbalize be avoided. doctor even if was able to
process as understanding of symptoms verbalize
RR- 25
evidenced by the etiology and subside. understanding
Wong baker scale inflamed management of Rationale: of the etiology
tonsils tonsillitis of her - To completely and
Subjective: child. destroy the management of
"nahihirapan nga After applying the bacteria. This the tonsillitis.
siya kumain. health teachings also prevents the The condition
masakit daw aang given to the resistance of the of the client
lalamunan niyä." As mother, patient's bacteria from the improved. The
verbalized by the condition will antibiotic. Goal was met
patient's mother improve arid
recurrence of the -Advise mother
infection will be to avoid giving
-sore throat avoided. sweets and cold
beverage to the
patient.
Rationale:
Bacteria
proliferate faster
in sweet
environment.

-Encourage
mother to do
tepid sponge bath
in case fever
persists.
Rationale:
Tepid sponge
bath decreases
the body's
temperature
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

through
conduction.

-Teach mother
how to properly
suction the
patient of
secretions.
Rationale:
Proper suctioning
will relieve the
patient of
difficulty
breathing as
secretions may
obstruct the air
way
- Promote oral
fluid intake

Rationale:
-Without proper
nutrition and
hydration the oral
mucosa is more
vulnerable to
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

Drug Study

DRUG NAME ACTION INDICATION CONTRA ADVERSE NURSING

INDICATIONS REACTIO CONSIDERATI
N ON

Generic Name: Penicillin V Penicillin Contraindications Frequency Before prescribing

Penicillin V exerts a V potassium tab of penicillin Not Defined penicillin to a
bactericidal actio lets are include a previous patient, the
Brand Name: n against penicill indicated in the history of severe  Diarrhea clinician and
Penicillin VK in-sensitive treatment of allergic reaction or healthcare
microorganisms mild to penicillin and its  Nausea team should
Dosage: during the stage moderately derivatives. confirm that
of active severe Penicillin is also  Oral the underlying
oral solution multiplication. It infections due contraindicated in candidia infection is likely
acts through the to penicillin G- patients who have sis the result of a
125mg/5mL inhibition of sensitive had Stevens- bacteria that is
biosynthesis of microorganisms Johnson syndrome  Vomitin sensitive to
250mg/5mL cell-wall . Therapy after the g penicillin.
mucopeptide. It should be administration of
tablet is not active guided by penicillin or a  Seizure The clinician,
against the bacteriological penicillin pharmacist, and/or
250mg penicillinase- studies derivative. The  Anemia nurse should also
producing (including penicillins are safe tell the patient of
500mg bacteria, which sensitivity tests) to use during any side effects of
 Interstiti
include many and by clinical pregnancy and the drug that
al
Route: Oral strains of response. nursing, as the should prompt
nephritis
staphylococci. drug appears at a a return visit, such
NOTE: low concentration as prolonged
 Hyperse
Severe pneumo in breastmilk. diarrhea or serious
nsitivity
nia, empyema,  Although renal rash.
bacteremia, peri impairment is not
carditis, mening a contraindication  Anaphyl The
itis, for penicillin, axis pharmacist should
and arthritis sho doses will have to consult the patient
uld not be be adjusted given  Positive on how best to
treated with end-stage renal Coombs administer
penicillin V disease. These reaction penicillin as well
during the acute patients will as reminding them
stage. Indicated receive a full that they should
surgical loading dose and complete the entire
procedures then half a loading course of the
should be dose every 8 to 10 antibiotic. Should
performed. hours or 4 to 5 a patient have
hours, depending difficulty
The following on the glomerular obtaining drugs for
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

infections will filtration either financial or

usually respond rate. Penicillin has logistical reasons,
to adequate an antagonistic a social worker
dosage of effect with may help to assure
penicillin V. tetracycline and that the patient
reportedly can lead receives his or her
to 2.6 times greater medications. In an
risk for mortality inpatient setting,
when treating communication
pneumococcal between the
meningitis clinician and the
compared to using nurse will allow
penicillin alone. the patient to
Penicillin requires receive the drug.
bacterial cell wall
synthesis to be
active to be
effective.