M. Gómez de Pablos Romero*, M. Sánchez Martín**
*Residente de Pediatría del Hospital Universitario de Móstoles. **Residente de Pediatría del Hospital Universitario La Paz.
12. Sore throat. Outpatient appointment
Doctor: Hello, I’m Dr. Chapman. What brings you here this morning?
Mother: Hello Dr. Chapman, my son John has been refusing to eat and has been cranky during the last couple of days. Today he is also feverish.
Doctor: John is a healthy boy if I remember. How old is he now? How much fever has he had? Tell me a bit more about his loss of appetite. Is he drinking enough?
Mother: He is 3 years old. He has had high temperatures up to 38.2ºC. He is eating very badly, but drinks plenty of water and juice.
Doctor: OK. Does he have any other symptoms? Cough, runny nose, diarrhoea, vomits?
Mother: Yes, he has been coughing a bit for the las three days and he has a runny nose, as always. He vomits sometimes when he coughs and lately he has been pointing to his throat.
Doctor: Does he attend nursery school? Is anyone else ill at home?
Mother: Yes, he began nursery school last year. At home it’s only John, his dad and me and both his father and I aren’t sick.
Doctor: OK then. Let’s take a look at John. Could you please take off his clothes?
Physical examination: Good general condition. Well nourished and hydrated. Capillary refill time: 2 seconds. No respiratory distress. Cardiac auscultation: regular, no heart murmur. Pulmonary auscultation: general good bilateral ventilation, no pathological breath sounds. HEENT: hyperemic oropharynx and swollen tonsils, without exudates. Normal tympanic membranes. Small, rubbery, mobile and nontender submandibular and laterocervical bilateral adenopathy. Abdomen: soft, nontender to palpation. No liver edge or spleen felt. No masses. Neurological: awake, alert, and fully orientated.
Doctor: Your son has a sore throat. There are no other findings on the physical examination. He seems to have an acute tonsillopharyngitis. This could explain the fact that he has been eating less, since his throat must be very painful making swallowing difficult. As long as he maintains a good liquid intake and stays well hydrated this shouldn’t worry you.
Mother: Will he need any other tests?
Doctor: In his case this will not be necessary since the diagnosis is quite clear based on clinical signs and symptoms. Tonsillopharyngitis can be caused by viruses or bacteria. In smaller children like John, viral tonsillopharyngitis is more common. It is usually associated to a common cold and normally there are no white spots on the tonsils, although sometimes they can appear. On the other hand, bacterial tonsillopharyngitis is more frequent in older children and usually presents with high fever, no cold symptoms, and large yellowish-white patches on tonsils. These patients may also refer a headache or abdominal pain. Bacterial tonsillopharyngitis is usually caused by a bacterium named Streptococcus pyogenes, which can also produce scarlet fever. In this case you can feel a rough rash on the child’s skin. A Rapid strep Test could be helpful in uncertain cases to rule out or confirm this bacterium. However, because of John’s age and associated symptoms, like coughing and a runny nose, this is highly unlikely. He probably has a mild viral infection.
Mother: Does that mean he has to take antibiotics?
Doctor: He doesn’t need antibiotics. These are useful for bacterial infections, which your son doesn’t seem to have, but they are not beneficial in infections produced by viruses. He will only need symptomatic treatment for the fever and the throat pain with analgesic and antipyretic drugs, such as paracetamol or ibuprofen, which is also anti-inflammatory.
Mother: So will he get better soon? For how long will the fever last?
Doctor: In these type of viral diseases fever can last from three to five days more or less. Don’t worry, you’ll see that he gets better soon. Nevertheless, if he still has fever on Monday and he’s not feeling well, I would like to check on him.
Sore throat: garganta irritada/odinofagia.
Healthy boy: niño sano.
Loss of appetite: pérdida de apetito.
Runny nose: rinorrea.
Nursery school: guardería.
Ill, sick: enfermo.
Let’s take a look: vamos a echarle un vistazo.
Hyperemic oropharynx: faringe hiperémica.
Swollen tonsils: amígdalas inflamadas.
Small, rubbery, mobile and nontender: pequeñas, elásticas, móviles y no dolorosas.
Acute tonsillopharyngitis: faringoamigdalitis aguda.
Swallowing (to swallow): tragar.
Liquid intake: ingesta de líquidos.
White spots/ yellowish-white patches: placas (exudados amigdalares).
Scarlet fever: escarlatina.
Rapid strep test: test rápido de estreptococo.
Associated symptoms: síntomas asociados.
Mild viral infection: infección viral leve.
Symptomatic treatment: tratamiento sintomático.
Analgesic, antipyretic and anti-inflammatory drugs: fármacos analgésicos, antipiréticos y anti-inflamatorios.
Check on (a patient): vigilar, controlar (al paciente).