For Examiner Only
Case Adult Epiglottitis
Author; Jennifer Jarecki, D.O.
Reviewer; Douglas Char, MD
Approved; 10/25/05
ORAL CASE SUMMARY
CONTENT AREA
Infectious Disease, ENT
SYNOPSIS OF CASE
39 yo male with c/o sore throat and odynophagia progressive over the past 12 hours
SYNOPSIS OF HISTORY
39 yo male presents to the ED with his wife- pt. c/o a 12 hour h/o fever and sore throat , with
progressive odynophagia. The patient awoke this morning with a sore throat and mild fever. No
associated URI symptoms.No recent ill contacts.His wife states that his voice has been hoarse
since onset of symptoms. The patient came to the ED because he was concerned that when he
went to lie down this pm he began choking and had trouble breathing. His wife states his
breathing "sounded funny."
SYNOPSIS OF PHYSICAL
wd/wn 39 yo male sitting up on stretcher, anxious appearing.
vs's: T:102.4 p: 110 R: 16 BP: 140/80 Pulse ox: 96% RA
HEENT: Mouth-pink dry mm's
Throat: mild erythema posterior pharynx; no tonsilar erythema or exudates; uvula midline
Neck: + b/l upper anterior cervical lymphadenopathy; + ttp upper anterior neck ; No masses/no
thyromegaly
Lung: CTA b/l no r/r/w; Pt. taking deep breathes; no stridor
Labs: CBC: wbc 12.5 ;hgb 14;hct 39; plt 350
Rapid strep: Negative
Throat cx: Pnd
CXR: Normal
Soft tissue lat. neck: Prominent epiglottis
Nasopharyngeal Laryngoscopy (if performed with trepidation): red, swollen epiglottis
CRITICAL ACTIONS
1. Prepare for possible emergent/surgical airway management
2. IV antibiotics
3. Antipyretic (+/-)
4. Consult ENT
5. Consult Anesthesia and/or surgery
6. Soft tissue neck film or NPL
7. Admit to ICU
SCORING GUIDELINES
(Critical Action No.)
Main issue is to recognize threaten airway and to avoid causing more edema which could
precipitate airway closure. Provider must be prepared to secure a surgical airway
FOR EXAMINER ONLY
For Examiner Only
PLAY OF CASE GUIDELINES
(Critical Action No.)
The examinee should approach the management of this patient cautiously. On evaluation in
the ED, the patient is stable, and in no acute distress. The patient’s wife provides a history
suggestive of a potential airway obstruction. If the candidate attempts to lie the patient back or
down for the exam, the patient becomes agitated, with persistant coughing, and becomes
stridorous. The candidate may choose to treat the patient with racemic epinephrine or steroids.
These are not critical actions in the management of this case, as these treatments have not
proven to be helpful in the management of acute epiglottitis. If the candidate attempts to send the
patient home as a viral pharyngitis, the patient develops respiratory distress upon dischargecoughing, stridorous, with agitation.
FOR EXAMINER ONLY
For Examiner Only
Critical Actions
1. Prepare for possible emergent airway management
This critical action is met by
Cueing Guideline:
Candidate requests for oral and surgical airway equipment to be brought to
the bedside. This should be ordered after interpretation of soft tissue lateral neck xray or
after bedside NPL in ED.
2.
Order IV Antibiotics
This critical action is met by
Cueing Guideline: Once candidate comes to the diagnosis of epiglottitis, Candidate should
order IV antibiotics to cover the most likely pathologic etiologies (group A strep.
Pneumoniae; staph. Pyogenes, and H. flu)
3.
Soft tissue lateral neck X-ray or bedside NPL
This critical action is met by
Cueing Guideline: This should be ordered after physical exam of oropharynyx proves to be
underwhelming and rapid strep test (if performed) is reported to be negative.
4.
Consult ENT
This critical action is met by
Cueing Guideline:
This consult should be ordered once the diagnosis of epiglottitis
is made. If the candidate doesn’t call the consult initially, the ICU physician may inquire about an
ENT consult when they are consulted for admission.
5.
Consult Anesthesia and/or Surgery
This critical action is met by
Cueing Guideline:
This consult should be called when the diagnosis of epiglottitis is made,
noting that the reason for the consult is the potential for development of an airway
obstruction.
6.
Admit to ICU
This critical action is met by
Cueing Guideline: The candidate should admit the patient to the ICU for observation – potential
for development of acute airway obstruction.
For Examiner Only
Case
Adult Epiglottitis
History Data Panel
Age: 39
Sex: Male
Method of Transportation: Car
Name:
John Jones
Person giving information: Patient and wife
Presenting complaint: Sore throat
Onset and Description of Complaint: 39 yo male presents to the ED with his wife- pt. c/o a 12
hour h/o fever and sore throat , with progressive odynophagia. The patient awoke this morning
with a sore throat and mild fever. No associated URI symptoms.No recent ill contacts.His wife
states that his voice has been hoarse since onset of symptoms. The patient came to the ED
because he was concerned that when he went to lie down this pm he began choking and had
trouble breathing. his wife states his breathing "sounded funny."
Past Medical History
Allergies: NKDA
Medical:
None
Surgical: None
Last Meal: 12 hours PTA ( secondary to progressive odynophagia)
Habits
Smoking:
1 ppd X 20 years
Drugs: no
Alcohol: social
Family Medical History
Father: HTN
Mother: None
Siblings: None
Social History
Married: Yes- 10 years
Children: two sons
Employed:
yes – Johnson and Johnson pharmaceutical rep.
Education: B.S. Biology Rutgers University
PMD: None
For Examiner Only
Case Adult Epiglottitis
Physical Data Panel
General Appearance: wd/wn 39 yo male sitting up on stretcher, anxious appearing . Patient
speaks in a hoarse voice.
Vital Signs:
BP
:140/80
P
:110
R
:18
T
:102.4 oral
O2Sat
:96 % RA
Glucose :90
Neurological:
Non-focal
Mental Status: AAOX3
Head:
AT/NC
Eyes: perl
Ears:
Tm’s clear
Mouth: pink, dry mucous membranes
Neck:
(+) b/l upper anterior cervical lymphadenopathy (+) tenderness to palpation upper
anterior neck; no thyromegaly
Skin:
no rashes
Chest:
CTA b/l no rales, rhonchi or wheezes. Patient is taking deep breaths. No stridor.
Heart:
regular; no rub
Abdomen:
soft; NT/ND
Extremities:
no C/C/E
Rectal:
not done
Pelvic:
not done
Back:
not done
Other exam findings:
Throat: Minimal erythema posterior pharynx with mild b/l tonsilar
enlargement; no exudate; uvula midline.
For Examiner Only
Case Adult epiglottitis
Lab Data Panel
Stimulus #2 – CBC
WBC
Hgb
Hct
Platelets
Differential
Segs
Lymphs
Monos
Eos
12.5/mm3
14g/dL
39%
350/mm3
%
%
%
%
Stimulus #3 – Chemistry
Na+ 140
mEq/L
K+4.6
mEq/L
HCO3-23
mEq/L
Cl-100
mEq/L
Glucose95
mg/dL
BUN18
mg/dL
Creatinine0.8
mg/dL
Stimulus #4 – Urinalysis N/A
Color
Yellow
Sp Gravity
1.
Glucose
Negative
Protein
Negative
Ketone
Negative
Leuk. Est.
Negative
Nitrite
Negative
WBC
/HPF
RBC
/HPF
Stimulus #5 –
Rapid Strep Test: Negative
Stimulus #6 –
Blood culture:Pending
Stimulus #7 – Throat Culture: pending
Stimulus #8 –
CXR: normal
Stimulus #9 – Soft tissue lateral neck X-ray:
prominent epiglottis
Stimulus #10 – NPL( if performed): red,
swollen epiglottis
VERBAL REPORTS
For Examiner Only
Stimulus Inventory
Stimulus #1 – Emergency Admitting Form
Stimulus #2 – CBC
Stimulus #3 – Chemistry
Stimulus #4 – Rapid Strep Test
Stimulus #5 – CXR
Stimulus #6 – Throat culture
Stimulus #7 – Blood culture
Stimulus #8 – Soft tissue lateral neck X-ray
Stimulus #9 – Bedside NPL
FOR EXAMINER ONLY
Mock Oral Feedback Form – ABEM model
Date:
Examiner:
Examinee:
Data acquisition
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Problem solving
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Patient management
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Resource utilization
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Health care provided
Worst
1
2
NOTES
3
4
5
6
7
8
Best
4
5
6
7
8
Best
Comprehension of path physiology
Worst
1
2
3
4
NOTES
5
6
7
8
Best
Clinical competence (overall)
Worst
1
2
3
NOTES
5
6
7
8
Best
Patient Interpersonal relations
Worst
1
2
3
NOTES
4
Critical Actions
Dangerous actions
1.
Prepare for possible emergent airway management
 and omissions
2.
Soft tissue neck x-ray or NPL
 1)Lie patient down for
3.
Consult ENT
4.
Consult Anesthesia and/ or surgery
 exam
 2) Discharge patient
5.
Admit to ICU
6.
 as a viral pharyngitis

7.

FOR EXAMINER ONLY
Mock Oral Feedback Form – Core Competencies
Date:
Examiner:
Does not meet
expectations
Examinee:
Meets
Expectations
Exceeds
Expectations
1. Patient care
2. Medical
knowledge
3. Interpersonal
skills and
communication
4. Professionalism
5. Practice-based
learning and
improvement
6. Systems-based
practice
Critical Actions
Dangerous actions
1.
Prepare for possible emergent airway management
 and omissions
2.
Soft tissue neck x-ray or NPL
 1)Lie patient down for
3.
Consult ENT
 exam
4.
Consult Anesthesia and/ or surgery
5.
Admit to ICU
 2) Discharge patient
 as a viral pharyngitis
6.

7.

FOR EXAMINER ONLY
Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name
:
John Jones
Age
:
39
Sex
:
Male
Method of Transportation :
Car
Person giving information :
Patient and his wife
Presenting complaint
sore throat
:
Background: pt. c/o a 12 hour h/o fever and sore throat, with progressive
odynophagia. The patient awoke this morning with a sore throat and mild fever.
No associated URI symptoms. No recent ill contacts. His wife states that his
voice has been hoarse since onset of symptoms. The patient came to the ED
because he was concerned that when he went to lie down this pm he began
choking and had trouble breathing. His wife states his breathing "sounded funny."
Vital Signs
BP :140/80
P :110
R :18
T :102.4 oral
O2Sat :96 % RA
Glucose :90
Stimulus #2 – CBC
WBC
Hgb
Hct
Platelets
Differential
Segs
Lymphs
Monos
Eos
12.5/mm3
14g/dL
39%
350/mm3
%
%
%
%
Stimulus #3 – Chemistry
Na+
140 mEq/L
K+
4.6 mEq/L
HCO323 mEq/L
Cl100 mEq/L
Glucose
96 mg/dL
BUN
18 mg/dL
Creatinine
0.8 mg/dL
Stimulus #4 – Urinalysis N/A
Color
Yellow
Sp Gravity
1.
Glucose
Negative
Protein
Negative
Ketone
Negative
Leuk. Est.
Negative
Nitrite
Negative
WBC
/HPF
RBC
/HPF
Stimulus #5 – CXR
Stimulus #6
Throat culture – pending
Stimulus #7
Blood culture - pending
Stimulus #8- Soft tissue lateral neck
Stimulus#9 NPL