Case Study: Sore throat Patient Information: L.A., 25 year-old, male, college student Chief Complaint: Sore throat History of Present Illness Onset: 7 days ago however, since yesterday, he has noticed that his eyes and skin have turned a yellow color. Location: throat associated with swollen and tender neck glands. (is the symptom located in a particular place? if no particular location, you can put “generalized”) Duration: 7 days ago, he developed fever which was low (99 F) to moderate grade (101.1 F). This was associated with swollen and tender neck glands. (how long has the condition lasted? recent or chronic?constant or intermittent? same as past problem and what has been done at that time? is it getting better, same or worse?) Characteristics/Course: He has sore throat but denies having cough, associated with swollen and tender neck glands. Denies abdominal pain but feels as if his upper abdomen has become swollen and he has lost his appetite. Aggravating/Associated Factors: Unknown Relieving Factors: Unknown Treatment: He denies taking any medications. Allergy: Unknown Past Medical History: Patient denied any history of jaundice, hepatitis, blood transfusion, body piercing, tattoos or eating shellfish. Surgical History: Patient denied previous surgery. No known drug allergies. Family History: Family history is non-contributory. Social History: Patient is a collage student who denied use of tobacco, alcoholic drinks or illicit drug.
Review of Systems: Constitutional: Patient is well-developed, in no acute distress. He appears concerned and anxious. Skin – no rashes, no itching, no hair changes or hair loss, no nail changes. HEENT – PERRLA, EOMI, (+) icteric sclerae, (+) pink conjunctivae, T-P erythematous with exudates, no vertigo, no lightheadedness; no blurring of vision, no double vision no tearing; (+) sore throat; no ear discharge, no ringing in the ears, no ear pain, (+)swollen and tender neck glands Cardiovascular – no chest pain, no palpitation Respiratory – no difficulty breathing, no cough Gastrointestinal – (+) loss of appetite, no nausea, no vomiting, no changes in bowel habits Genitourinary – no changes in urination, no pain in urination, Neurologic – no difficulties with speech, memory and motor coordination; no numbness or tingling sensation Musculoskeletal – (+) muscle aches, no pain or tenderness of the joints, no muscular weakness or cramps. Hematologic: No anemia, bleeding or bruising. Lymphatics: (+) enlarged nodes. Psychiatric: appears concerned and anxious no change in orientation Endocrine: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. Allergies: no seasonal allergies
PHYSICAL EXAMINATION General – patient is awake, alert, weak looking. Patient is well-developed, in no acute distress. He appears concerned and anxious. Vital signs VS: BP – 130/80, PR- 110/min, RR – 20/min, T – 101.4 F, SpO2 – 99%. Skin – moist, no rashes, no bruising, face is flushed HEENT – Normocephalic, normal hair texture, no scalp lesion or tenderness; icteric sclera, pink conjunctiva, extraocular muscle movement intact, pupils equal and reactive to light and accommodation, present red reflex on fundoscopy; no external ear lesions, tympanic membrane is translucent with positive cone of light on both ears, no ear discharge noted; midline nasal septum, no tongue lesions noted, no gum bleeding noted; tonsils and pharyngeal walls noted erythematous with exudates, Neck –posterior cervical lymph nodes swollen, tender and movable, bilaterally. Supraclavicular lymph nodes not enlarged. Heart – PMI palpable in the left 5th intercostals space, midclavicular line, tachycardia, with HR of 110, no murmurs noted Thorax and back – symmetrical chest expansion with breathing, no spinal tenderness, and no costovertebral angle tenderness Lungs – normal resonance on percussion, clear and equal breath sounds, no crackles, wheezing or rhonchi Abdomen – Normal bowel sounds, liver – 14 cm in midclavicular line by percussion, diffuse tenderness over both right and left upper quardrants on palpation.
Extremities – no cyanosis, no clubbing of the nails, no edema, normal range of motion, pulses normal with regular rhythm. Neurologic – patient is awake, alert, oriented to person, place and time; speech is clear and concise, cranial nerves intact; normal muscle tone, no loss of sensation; deep tendon reflexes are 2/4, no problems with motor coordination. Psychiatric: Oriented ASSESSMENT(one primary diagnosis and 2 differential diagnoses) Primary Diagnosis: The most common bacterial infection of the throat is strep throat, which is caused by Group A streptococcus. Rare causes of bacterial pharyngitis include gonorrhea, chlamydia, and corynebacterium. This can be confirmed by doing rapid strep test, and throat culture. Other possible causative organism is hepatitis A, A highly contagious liver infection caused by the hepatitis A virus that spreads from contaminated food or water, or contact with someone who is infected. Symptoms include fatigue, nausea, abdominal pain, loss of appetite, and low-grade fever. This ca easily be rulled out by doing liver fi\unction panel laboratory blood test (Brady, 2009, p. 773). Differential Diagnoses: 1. Gilbert’s syndrome which presents with skin and the whites of the eyes to have a yellow tinge due to the buildup of bilirubin. It can be ruled in or out by doing CBC and liver function test. The combination of normal blood and liver function tests and elevated bilirubin levels is an indicator of Gilbert’s syndrome. No other testing usually is needed, although genetic testing can confirm the diagnosis. (Luzuriaga & Sullivan, 2010). Management of IM is usually supportive. 2. Infectious Mononucleosis Often called mono or kissing disease, an infection with the Epstein-Barr virus ( ). Symptoms include fatigue, fever, rash, and swollen glands that matches the chief complaints of the our patient.
PLAN Diagnostics: Strep assay was done and it turned out to be positive. It is recommended though that throat culture for confirmation is done for those with negative rapid antigen test to reduce the unnecessary use of antibiotics (McIsaac, Kellner, Aufricht, Vanjaka, & Low, 2004). Blood panel of CBC was done to determine if there are other type of infection in which case is negative. Hepatitis A,B and C serology is a series of blood tests used to detect current or past infection by hepatitis A, hepatitis B, or hepatitis C. It can screen blood samples for more than one kind of hepatitis virus at the same time, there were no hepatitis antibodies found therefore the result was negative. Lastly uultrasound of the liver was performrd to detect any abnormalities and the cause of an on going symptom, our patient was result revereled normal liver in fi\unction and size. Screening: none Rx: Penicilline 500 mg/125 mg by mouth every 12 hours for 10 days and instructed to finish the course of the medication even if he feels better already to prevent complications such as rheumatic fever, or abscess formation. Ten days therapy is recommended to maximally eradicate group A streptococcus (Bisno, Gerber, Gwaltney, Kaplan, & Schwartz, 2002). Education: Home instructions: increase oral fluid intake and rest; avoid close contact with anyone with strep throat; avoid germs; wash hands often; gargle with a solution of 1/4 teaspoon of salt mixed in 1 cup of warm water; stick to foods that are soft and easy on the throat (applesauce and yogurt are good choices) or warm and soothing (such as broth or tea); stay away from anything spicy or acidic; get lots of sleep and drink a lot of water; change toothbrush; Consult/Referral: Alert Provider if the following occur during treatment: fever recurs after being normal for a few days, new symptoms appear, such as nausea, vomiting, earache, cough, swollen glands, skin rash, severe headache, nasal drainage, or shortness of breath, joints become red or painful. Follow-up: To come back to clinic after 2 days if still with fever or no improvement of symptoms.