1. Case Presentation By Jesper Aurup

2. Triage 47yo Female with dyspnea T-100.6, PR- 110, BP- 142/86, RR- 20, O2- 99% on NC 15L, BMI-84 “Inhaled roach spray”

3. Chief Complaint “I inhaled some Roach powder and it hurts to breathe”

4. History of Present Illness 47yoF with PMH of asthma, HTN, sleep apnea, arthritis, and hyperlipidemia presents with dyspnea of acute onset. The patient has felt weak for the past few days and has had a sore throat and trouble swallowing for the past 2 days. She stated that her throat had been feeling dry and it hurt to breathe. She stated drinking water helped to alleviate the pain. At 3:30pm on the day of her presentation to the ED, the patient was cleaning and putting away a roach powder that then fell out of the cabinet exploded up into her face and she stated that she inhaled some of it. At 5:00pm the patient began having a cough, nausea, and feeling feverish so she took 2 Tylenols PO. The patient then took 2 puffs of her albuterol inhaler to help with her cough. Later, she still felt ill and her daughter convinced her to call an ambulance. Pertinent Positives: Fever, cough, sore throat, pain on swallow, nausea, dyspnea Pertinent Negatives: No chest pain, stiff neck, stridor, drooling, inability to swallow, headache, abdominal pain, vomiting, or recent sick contacts

5. Other History, Allergies, and Medications PMH: Asthma, HTN, Hyperlipidemia, Sleep apnea, Arthritis PSH: Gastric Sleeve March 2015, C Section 1993 FH: Mother had CAD, Father had Diabetes Type 2, Daughter has asthma SH: lives with her daughter. Former smoker. 20 pack year history All: Motrin – rash, Advil – rash Meds: albuterol nebulizers

6. Physical Exam Vital Signs: T-100.6, PR- 110, BP- 142/86, RR- 20, O2- 99% on 2L, BMI-72 Gen: Minimal distress, sitting upright, able to hold conversation CV: s1s2, regular rhythm, tachycardic, no mgr Resp: CTAB, good air entry, no wheezes, no stridor, no accessory muscle use, no drooling HEENT: PERRLA, EOMI, no palpaple cervical adenopathy (limited exam due to obese neck), however was tender to palpation over anterior neck, erythematous oropharynx, white tonsillar exudates bilaterally

8. Roach Powder- Generally Boric Acid is Poisonous Ingredient Symptoms: Blue-green vomit Diarrhea Bright red rash Fever Low BP Decreased UO Drowsiness Management: ABCs IV fluids Gastric Lavage and Activated charcoal if ingested

9. Differential Diagnosis of Sore Throat S.P.I.T. Severe – Epiglottitis, Peritonsillar Abscess, Ludwig Angina Probable – Viral Pharyngitis, Bacterial Pharyngitis Interesting – Retropharyngeal abscess Treatment – Evaluate the need for supportive care with or without antibiotics

10. Clinical PresentationDiagnosisTreatment EpiglottitisSudden Onset of Fever Drooling Tachypnea Toxic Appearing Lateral Cervical Radiography Urgent ENT consult Cefuroxime Antibiotic Therapy Retropharyngeal AbscessFever Sore throat Stiff Neck No Trismus Lateral Radiograph or CTSurgical drainage Penicillin and Metronidazole Ludwig AnginaSubmaxillary mass with elevation of tongue Jaw swelling Fever Trismus Lateral cervical radiograph or CT Stabilize airway Surgical drainage Penicillin and Metronidazole

12. Imaging and EKG findings Chest X ray – No pleural effusion, no focal consolidation, no pneumothorax, normal heart size, normal heart border EKG – Sinus Tachycardia

13. Laboratory Values CBC 10.4>12.0/38.2<250 BMP: Na- 143, K-3.7, Cl- 105, HCO3- 23, BUN- 13, Cr-1.4, Glu-105 LFT: Tbili-04, AlkPhos- 94, AST-11, ALT-10 BHcG- negative PT- 10.0, INR- 0.9, aPTT-26.7 CPK – 138, TropT- <0.01 Lactate – 0.9 Amylase – 48, Lipase – 12 AND???????

14. Rapid Group A Strep Test

15. Because…. CENTOR Criteria for predicting Streptococcal Pharyngitis (2) Presence of Tonsillar Exudates: 1 point Tender Anterior Cervical Adenopathy: 1 point Fever by history: 1 point Absence of Cough: 1 point Age less than 15years old: 1 point Age more than 45years old: Subtract 1 point

17. Our Patient’s Score…. 2 to 3 Presence of Tonsillar Exudates: 1 point Tender Anterior Cervical Adenopathy: 1 point Fever by history: 1 point Absence of Cough: 1 point Age less than 15years old: 1 point Age more than 45years old: Subtract 1 point

18. Assessment and Plan 47yoF with positive RAST test and signs and symptoms consistent with Streptococcal Pharyngitis. The patient was given: Tylenol 650mg PO Dexamethasone PO 10mg Penicillin G IM 1.2MIL U And discharged home

20. Journal of Family Practice July 2013 A meta analysis of 8 RCTs with an overall population of 806 (children and adults) was 44% positive for GAS and treated with antibiotics and allowed traditional analgesia with acetaminophen or NSAIDs with possible adjunctive corticosteroid vs placebo Overall, patients who received corticosteroids were 3 times more likely to report pain relief at 6 hours and resolution of symptoms at 24 hours. NNT <4 In addition, one RCT found that 16% of placebo patients returned for additional care vs none in steroid group Adverse Events: Reported in one RCT (n=125): 3 steroid vs 2 placebo were hospitalized for rehydration and 3 steroid vs 2 placebo developed peritonsillar abscess Of note, it was found single vs multiple doses were effective with statistically insignificant differences in results

21. Clinical Pearls The Rapid Strep Test has a Sensitivity of 64.6% and Specificity of 96.79%, with PPV of 80.95% (1) Throat Cultures are the Gold Standard for GAS Pharyngitis, but they require 24-48hours for results(3) Treatment of Group A Strep Pharyngitis is to prevent sequelae of GAS Pharyngitis such as Rheumatic fever and Meningitis (3) The most common cause of pharyngitis is viral (3) Steroids can be used in Strep Throat for improvement of pain and swelling. Standard dose is Dexamethasone 0.6mg/kg up to 10mg PO or IM (3)

22. References 1) Gurol Y, Akan H. The sensitivity and specificity of rapid antigen test in streptococcal upper respiratory infections. Int J Pediatrics. 2010. 2) McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE. Empirical Validation of Guidelines for the Management of Pharyngitis in Children and Adults. JAMA. 2004;291(13):1587-1595. doi:10.1001/jama.291.13.1587. 3) Case Files: Emergency Medicine 3 rd Edition