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Diagnosis at a glance.

Cook S; Allen A; Parker-Sayre A

Emerg Med 2005 Nov; 37(11):31-32

20049539

CASE I: A 60-year-old woman presents to the emergency department complaining of a sore, swollen throat, difficulty swallowing, decreased oral intake, hoarseness, fever, and chills. When her symptoms began three days ago, she contacted her primary care physician , who prescribed azithromycin. Although she started the antibiotic immediately, her symptoms worsened. Her vital signs are: temperature, 100 degrees F; pulse, 100 bpm; respiratory rate, 18; blood pressure, 139/92 mm Hg; and oxygen saturation, 96% on room air. Physical examination finds a red, warm, swollen, tender area over the anterior neck. What is your diagnosis? CASE 2: A 75-year-old man presents to the emergency department complaining of a rash on the right side of his face that has persisted for three days. He denies any trauma and states that there has been no change in his household or hygiene products, food exposures, or medications. He denies itching but does have some burning pain in his right ear and at the site of the eruption. His vital signs are: temperature, 97.8 degreesF; pulse, 98 bpm; respiratory rate, 18; blood pressure, 150/73 mm Hg; and oxygen saturation, 95% on room air. Physical examination finds the patients face unilaterally affected by patchy erythema, vesicles, and palsy. What is your diagnosis? CASE I - Acute epiglottitis (supraglottitis) is a rapidly progressive cellulitis of the epiglottis and surrounding soft tissues in the supraglottic airway that can cause acute airway obstruction requiring surgical intervention. Frequent signs and symptoms of acute epiglottitis include fever, leukocytosis, dysphagia , odynophagia, hoarseness, drooling, stridor, tripod positioning, and an erythematous and edematous epiglottis. In adults, the best way to confirm the diagnosis is with fiberoptic examination of the supraglottis. Radiographic and computed tomography (CT) imaging of the soft tissue of the neck can aid in the diagnosis. The lateral neck film will show a "thumb sign" (enlarged epiglottis) and the CT scan will demonstrate supraglottic edema. In this case, the patient's CT scan showed extensive inflammatory and edematous changes of the supraglottis, including the epiglottis, pre-epiglottic space, paralaryngeal space, pharyngeal space, and the base of the tongue. CASE 2 - This patient exhibits Ramsay-Hunt syndrome, an acute herpes zoster (shingles) infection involving the facial nerve (cranial nerve VII). The hallmark of the diagnosis is the physical examination demonstrating grouped vesicles on an erythematous base in a dermatomal distribution, accompanied by facial palsy or droop (Bells palsy). The patient may also experience taste loss in the anterior tongue, tinnitus, hearing loss, vertigo, and ear pain. There may be lesions in the external auditory meatus as well as the pharynx. A typical history includes several days of itching, burning, tingling, numbness, pain in the area of a dermatome, or some combination of these symptoms, followed by a vesicular rash with a red base in the same distribution. The rash is preceded by paresthesias or dysesthesias and often followed by hypalgesia or hypesthesia after the rash resolves (postherpetic neuralgia).

Humans; Men; Women; Diagnostic tests; Diseases; Temperature effects; Physiological effects; Physiology; Physiological testing; Physical examination

20051101

Journal Article

Grant

2006

Grant-Number-T01-OH-008431

11

0013-6654

Emergency Medicine

WV

West Virginia University