Since his rapid antigen test was negative, the patient should receive a
throat cultureand be treated only if the results are positive. In addition, he
should be treated symptomatically with fluids, topical anesthetics, and
acetaminophen or ibuprofen.
(a)According to the Centor criteria, the patient should not receive
antibiotics. The negative predictive value for is approximately 80%.
(b)There is no indication that this patient has lymphoma, his symptoms
are only present for 2 days. (c)Observation is unnecessary in this patient.
(e)Amantadine is used in the treatment of influenza, which typically pre-
sents with a high fever, myalgias, and headache. Cervical lymphadenopathy
is rare.
179.The answer is a.(Rosen, pp 975-977.)The patient’s presentation is
typical for a peritonsillar abscess.Signs and symptoms include a sore
throat, muffled voice, trismus, fluctuant mass, deviation of the uvula,
odynophagia, and drooling. Many of these patients have a history of being
recently treated for strep throat. The abscess is usually unilateral and in the
superior pole of the tonsil. Airway patency must be assessed because of the
obstructing potential of an abscess. Treatment includes either needle aspi-
rationorincision and drainageof the abscess, in addition to antibiotic
treatment.Some studies demonstrate the safety and cost-effectiveness of
needle aspiration over incision and drainage.
(b)The abscess will not resolve without an intervention. (c)Incision
and drainage of the abscess may be performed in the OR depending on the
size and degree of airway compromise. However, this is not necessary in
the patient described. (d)Drainage of the abscess is the most important
factor in treating these patients. Antibiotics alone are not sufficient. (e)A
CT scan may aid in the diagnosis of a peritonsillar abscess in patients with
severe trismus.
180.The answer is c.(Rosen, pp 977-978.)Ludwig anginais a poten-
tially fatal disease that can progress to death within hours. It is a
progressive cellulitisof the floor of the mouth and neckthat begins in
the submandibular space. A dental cause, such as an extraction, is present
in approximately 90% of cases. The most common symptoms include dys-
phagia, neck pain, and swelling. Physical findings include bilateral sub-
mandibular swelling, tongue swelling, and protrusion. A tense edema and
induration of the neck may occur that is described as a “bull neck.” Man-
agement involves securing an airway and starting IV antibiotic therapy
200 Emergency Medicine