HEENT Case Study

The case patient presents with several symptoms including a sore throat, headache, nasal discharge, dysphagia, and fever. Objective data shows that her tonsils red, swollen, and with white patches. Such symptoms lead to different ways of thought concerning her diagnosis since she reports no history of recent upper respiratory infection. As such, a study of differential diagnoses and several tests are required to determine her definitive diagnosis.

Differential Diagnoses

  1. Strep Throat

CPT ICD-1O Code- J02.0

            Strep throat is a bacterial condition that causes soreness in the human throat. It mostly affects children, and adults can also be infected. Symptoms of this disease include painful throat, fever, headache, nausea, and vomiting. On examining the throat, red and swollen tonsils may be observed. Also, white patches appear on the tonsils. Palpation of the neck reveals tender cervical lymph nodes.

  1. Acute Epiglottitis

CPT ICD-10 Code- J05-11

Acute epiglottitis occurs when the epiglottitis swells to the extent of blocking the windpipe and affecting air flow to the lungs. It is mostly caused by Haemophilus influenzae type b. Common symptoms include a severely sore throat, fever, abnormal and high-pitched sound, dysphagia, drooling, a hoarse voice in adults, and difficulty in breathing.

  1. Peritonsillar Abscess

CPT ICD-10 Code- J36

It is a bacterial infection that results as a complication of untreated strep throat or tonsillitis. Pus forms in pockets in some of the tonsils which then leads to the formation of an abscess. The major symptoms of this disease include fever, dysphagia, and difficulty in opening the mouth fully. Also, drooling, headache, and a sore throat are common symptoms. The patient may also have a muffled voice and a bad breath.

Definitive Diagnosis


CPT ICD-10 Codes- J03-90

            Although the case-patient showed some signs of the differential diagnoses discussed above, tonsillitis met all the symptoms attained from both subjective and objective data. Patients with tonsillitis usually have symptoms of a sore throat, fever, headache, nasal discharge, and dysphagia. Besides, they have a muffled voice on speaking. Examination of the throat reveals red, swollen tonsils with white patches. Also, halitosis is positive.

Diagnostic Tests for the Patient

  1. Strep Test

ICD-10 Code-87880

In this case, a swab is used to extract secretions from the throat. After that, the secretions are tested for the presence of Streptococcal bacteria. A positive bacterial test shows that the person has a bacterial infection (Nakao et al., 2018).

  1. Complete Blood Cell Count Test

ICD Code- 85027

This test is used to measure any decrease in the number of white blood cells and other cells that indicate the presence of a disease. A decrease in such cells shows the presence of an infection.

Treatment of Tonsillitis

            Bacterial Tonsillitis is managed using antibiotics. Currently, Amoxicillin, Clavulanic Acid, and Cephalosporins are used to treat the disease (Windfuhr, Toepfner, Steffen, Waldfahrer, & Berner, 2016). Since the patient is experiencing pain and fever, acetaminophen can be prescribed to cure those symptoms. Apart from medical management, the patient can be advised to get enough rest and drink cold fluids to ease throat pain.

Discharge Education

            Educating the patient before discharge is essential in necessitating quick recovery. In this case, the patient will be taught how to self-administer prescribed drugs. Besides, the patient will be advised to report to the healthcare facilities in case the symptoms persist after using the prescribed medication and following other measures that necessitate recovery.



Nakao, Y., Tanigawa, T., Kano, F., Tanaka, H., Katahira, N., Ogawa, T., … & Shibata, R. (2018). Diagnostic role of mean platelet volume in tonsillitis with and without peritonsillar abscess. The Journal of Laryngology & Otology, 132(7), 615-618.

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.