What should be given to a case of tonsils

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Here is a complete, textbook-based guide to the management of tonsillitis:

Management of Tonsillitis

1. Supportive (Symptomatic) Treatment - First Line for All Cases

The primary management of acute tonsillitis is symptomatic:

Analgesics - Paracetamol (acetaminophen) and/or NSAIDs to relieve pain and fever
Hydration - Encourage adequate fluid intake
Saline gargles - Soothing for throat pain
Wait for symptoms to resolve; most cases (both viral and bacterial) resolve quickly without antibiotics

(Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Bailey and Love's Short Practice of Surgery)

2. Antibiotics - When to Use

Antibiotics shorten the illness and reduce the risk of complications (rheumatic fever, glomerulonephritis, peritonsillar abscess). Start antibiotics:

If no improvement within 48-72 hours
Or immediately if the disease is clinically severe at presentation

Drug	Role
Benzyl-penicillin (Penicillin G) / Penicillin V (phenoxymethylpenicillin)	Drug of choice - no resistance reported for GABHS
Amoxicillin	Comparable efficacy; preferred in children (better taste of suspension)
10-day oral course	Recommended for complete pharyngeal eradication
Benzathine penicillin IM (single dose)	Equally effective alternative
Clarithromycin / 1st-generation cephalosporins	For penicillin-allergic patients
Clindamycin	For macrolide-resistant GABHS in penicillin-allergic patients

Important: Ampicillin must be avoided if infectious mononucleosis (EBV/glandular fever) is suspected - it causes a rash in ~90% of such patients. Amoxicillin causes rash in ~30% of EBV cases.

(Tintinalli's Emergency Medicine; Scott-Brown's Otorhinolaryngology; Bailey & Love)

3. Corticosteroids

In severe cases, corticosteroids (oral or IM) - in addition to antibiotics - expedite resolution of pain and throat swelling
Particularly useful when there is significant tonsillar swelling threatening the airway (e.g., in infectious mononucleosis)

(Scott-Brown's Otorhinolaryngology Head & Neck Surgery)

4. Infectious Mononucleosis Tonsillitis (Special Case)

High-dose IV penicillin or cephalosporins for hospitalized patients
Avoid ampicillin/amoxicillin
Corticosteroids if airway compromise or severe swallowing difficulty
Antiviral (acyclovir) - debatable; consider only in severe cases

5. Complications to Watch For

Complication	Action
Peritonsillar abscess (Quinsy)	IV penicillin or cephalosporin + needle aspiration / incision and drainage
Rheumatic fever	Treat GABHS promptly with penicillin
Glomerulonephritis	Antibiotic treatment; note: antibiotics may not prevent glomerulonephritis
Parapharyngeal abscess / septicaemia	Hospital admission, IV antibiotics, surgical drainage

6. Surgical Treatment - Tonsillectomy

Indicated when medical management is insufficient. Standard criteria (the Paradise criteria):

7 or more episodes in 1 year, OR
5 or more per year for 2 consecutive years, OR
3 or more per year for 3 consecutive years
> 2 weeks of school/work missed in 1 year
Tonsillar hypertrophy causing airway obstruction or sleep apnea
Peritonsillar abscess (recurrent)
Suspicion of malignancy
Diphtheria carrier state
Recurrent tonsillitis causing febrile seizures

Morbidity: post-op hemorrhage in ~2-4%; mortality 1 in 25,000.

(K.J. Lee's Essential Otolaryngology)

Summary in brief:

Mild/early: rest, analgesics, hydration, saline gargles
Bacterial / no improvement in 48-72h: Penicillin V or amoxicillin x 10 days
Severe / hospitalized: IV penicillin + steroids
Penicillin allergy: cephalosporin or clarithromycin
Recurrent / obstructive: tonsillectomy

What should be given if a fall occured and knee pain started

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Here is a comprehensive, textbook-based guide to managing knee pain following a fall:

Knee Pain After a Fall - Management Guide

Step 1: First Aid - RICE (Immediate, First 24-72 Hours)

RICE is the cornerstone of initial management for any traumatic knee injury:

Letter	Action	Detail
R - Rest	Avoid weight bearing	Limit activity; use crutches if walking is painful
I - Ice	Cold pack to the knee	20 minutes on, 20 minutes off; do NOT apply directly to skin
C - Compression	Elastic/crepe bandage	Reduces swelling; not too tight
E - Elevation	Raise the leg above heart level	Reduces swelling and pain

(Goldman-Cecil Medicine; Campbell's Operative Orthopaedics)

Step 2: Pain Relief (Medications)

Paracetamol (acetaminophen) - first choice analgesic for mild-moderate pain
NSAIDs (e.g., ibuprofen, naproxen, diclofenac) - anti-inflammatory AND analgesic; best given with food; avoid in peptic ulcer disease or renal impairment
Topical NSAIDs (e.g., diclofenac gel) - useful with less systemic side effects

Corticosteroid injections are generally less favored for acute traumatic knee injuries as they may weaken the structures.

(Goldman-Cecil Medicine)

Step 3: When to Get an X-Ray (Ottawa Knee Rules)

Do NOT assume every knee injury needs imaging. Order a knee X-ray only if one or more of the following are present:

Ottawa Knee Rules:

Age > 55 years
Isolated patellar tenderness (no other bone tenderness)
Isolated fibular head tenderness
Inability to flex the knee to 90 degrees
Inability to bear weight for 4 steps - both immediately after injury AND in the clinic/ED

(Rosen's Emergency Medicine; Tintinalli's Emergency Medicine)

These rules are 98.5% sensitive for fractures and help avoid unnecessary X-rays.

If X-ray is negative but fracture is still suspected: proceed to CT scan or immobilize and refer urgently to orthopaedics.

Step 4: Imaging Views to Request

If X-ray is ordered:

AP + lateral views (standard)
Sunrise (skyline) view - for patellar fracture
Tunnel/intercondylar view - for tibial spine fractures
Oblique view - for tibial plateau fractures
MRI - gold standard for soft tissue (ligament, meniscus) injuries

Step 5: Diagnose the Type of Injury

Injury Type	Key Features	Treatment
Soft tissue / sprain	Pain, swelling, no instability	RICE + NSAIDs + physiotherapy
ACL tear	"Pop" heard, rapid swelling (hemarthrosis), instability	RICE, orthopaedic referral, possible surgery
MCL/LCL sprain	Pain on valgus/varus stress testing	Grade 1-2: RICE + physio; Grade 3: may need surgery
Meniscus tear	Joint-line tenderness, locking or giving way	RICE, orthopaedic/arthroscopy referral
Patellar fracture	Patellar tenderness, inability to straight-leg raise	Non-displaced: cylinder cast; Displaced: surgery
Tibial plateau fracture	High-energy mechanism, swelling, X-ray ± CT	Orthopaedic referral; surgery if displaced
Hemarthrosis (blood in joint)	Tense, rapid swelling	Aspiration (arthrocentesis) for relief + diagnosis
Prepatellar bursitis	Swelling over the patella, "housemaid's knee"	RICE, NSAIDs; aspiration if large

(Tintinalli's Emergency Medicine; Rosen's Emergency Medicine)

Step 6: Red Flags - Refer Immediately

Deformity of the knee
Inability to weight bear at all
Neurovascular compromise (cold foot, absent pulses) - suspect popliteal artery injury in knee dislocation (limb-threatening emergency)
Open wound over the joint (open arthrotomy = surgical emergency + IV antibiotics)
Rapidly developing tense swelling (hemarthrosis)
Signs of infection (warmth, fever, septic arthritis)

Step 7: Follow-Up and Rehabilitation

Once acute swelling subsides: physiotherapy for quadriceps strengthening and range of motion
For ligament/meniscus injuries: orthopaedic follow-up and possible arthroscopy
Do NOT return to full activity until pain-free with full range of motion

Summary in brief:

Immediate: RICE + paracetamol/NSAIDs
Check: Apply Ottawa Knee Rules to decide if X-ray needed
Refer urgently if: unable to walk, deformity, vascular signs, open joint, suspected fracture
Follow-up: Physio + orthopaedics for ligament/meniscus injuries

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