As the patient’s chief complaints in the discussed case study include sore throat, tiredness, and painful swallowing, further examination will focus on detecting other symptoms connected to this condition. The rapid development of the symptoms, body temperature of 38 degrees centigrade, and enlarged anterior cervical lymph nodes show signs of an acute infection, which requires further observation. The left tonsil is enlarged and partially covered with white exudate, while the right tonsil is only slightly enlarged. Such a condition of the tonsils and the absence of other symptoms, such as cough or difficulty breathing, show that tonsillitis can be considered as a provisional diagnosis. Nevertheless, differential diagnosis and lab tests are needed to prove the assumption.
Differential diagnosis, in this case, must focus on such conditions as a common cold, scarlet fever, and infectious mononucleosis. In order to take one of these diagnoses into consideration, at least one symptom apart from fever and sore throat should be detected. Specific skin conditions and red dots on tonsils typical for scarlet fever are not identified in this case. At the same time, the absence of cough and difficulty breathing suggests that a common cold is not the diagnosis. According to Windfuhr et al. (2016), tonsillitis can be caused by infectious mononucleosis, which has similar symptoms, including swollen lymph nodes, and exudates on the tonsils. Thus, differential diagnosis supports the provisional one, but the lab tests are necessary to know its nature and prescribe a suitable treatment.
Treatment of acute tonsillitis depends on whether it is viral or bacterial, which often requires antibiotics. According to Windfuhr et al. (2016), 70-95% of all cases have viral epidemiology and persist for several days. Clinical symptoms of the discussed patient, white exudates, and absence of common cold symptoms, in particular, suggest that this infection can be caused by bacteria. Such tests as WBC count and WBC differential can provide information about the disease. According to Honda et al. (2016), the left shift in non-segmented/segmented neutrophils speaks of bacterial infection present in an organism. That is why the patient is diagnosed with acute tonsillitis caused by bacteria.
References
Honda, T., Uehara, T., Matsumoto, G., Arai, S., & Sugano, M. (2016). Neutrophil left shift and white blood cell count as markers of bacterial infection. Clinica Chimica Acta, 457, 46-53.
Windfuhr, J. P., Toepfner, N., Steffen, G., Waldfahrer, F., & Berner, R. (2016). Clinical practice guideline: Tonsillitis I. Diagnostics and nonsurgical management. European Archives of Oto-Rhino-Laryngology, 273(4), 973-987.