Clinical Case Study: Adult

Patient with
Pharyngotonsillitis
In this case study, we will analyze the clinical presentation, treatment, and
complications of a 30-year-old male patient who presented with fever, sore throat, red
spots on the palate, and odynophagia for more than 4 days. The patient's condition
was diagnosed as pharyngotonsillitis at the Emergency Department. Let's dive into
the details of this interesting case.

OR by OSCAR RIOJA
Clinical Presentation

Fever (39°C) Sore Throat Red Spots on Palate

The patient had a high-grade fever The patient experienced significant Patient's examination revealed the
of 39°C, indicating an active discomfort and pain in the throat. presence of red spots on the palate,
inflammatory process. indicating localized inflammation.
Treatment Plan

1 Penicillin Benzatine 2 Metamizol

A single intramuscular injection of Penicillin As part of the treatment plan, the patient was
Benzatine 600,000 UI was administered to the prescribed Metamizol to manage the fever and
patient. alleviate pain.

3 Azitromycin 4 Vancomycin

The patient received Azitromycin as an Due to the positive culture results for Clostridium
antimicrobial agent to target the infection. difficile, the patient was initiated on Vancomycin
therapy.
Complications
1 Generalized Itching

The day after administration, the patient experienced severe generalized itching,
particularly in the lumbar area.

2 Erythematous Macular Lesions

Within hours, the patient noticed the appearance of erythematous macular lesions on the
extremities, face, and trunk.

3 Gastrointestinal Symptoms

In addition to skin manifestations, the patient presented with diarrhea, nausea, and
stomach pain.
Additional Findings
The patient's clinical evaluation revealed a fever of 38.5°C, papular and
symmetrically distributed erythematous lesions throughout the body, and profuse
sweating. Blood pressure was elevated at 150/100 mmHg, heart rate at 105 beats per
minute, and respiratory rate at 24 breaths per minute. Laboratory tests confirmed a
positive Clostridium difficile culture.

Notably, the patient had a history of elevated cholesterol levels, triglycerides, and
was overweight.
Conclusion

Accurate Diagnosis Effective Treatment

Through comprehensive evaluation and laboratory The prescribed treatment plan that included
tests, the patient's condition was accurately Penicillin Benzatine, Metamizol, Azitromycin, and
diagnosed as pharyngotonsillitis with associated Vancomycin effectively controlled the infection.
complications.

Complications Management Addressing Comorbidities

Despite the development of adverse reactions, The patient's underlying comorbidities, such as
appropriate management strategies were employed elevated cholesterol levels and triglycerides, need to
to address the patient's symptoms. be addressed in the long-term management plan.
In Summary
This case study highlights the importance of accurate diagnosis, prompt treatment,
and vigilant management of complications in adult patients with pharyngotonsillitis.
By utilizing appropriate therapeutic interventions and closely monitoring adverse
reactions, healthcare professionals can optimize patient outcomes and ensure a
comprehensive approach to care.