Case Study: Sore Throat
Patient Information: Lyle Affleck, 25 -year old, male, Caucasian, college student.
Chief Complaint: Sore throat
History of Present Illness: This is a 25 years-old patient who came to clinic complaining of sore throat. Seven days ago, he developed fever which was low 99F, to moderate grade 101.1F. This was associated with swollen and tender neck glands. He has sore throat but denies having cough. He has no abdominal pain but feels as if his upper abdomen has been swollen and he has lost his appetite. He has no nausea or change in bowel movements. Since yesterday patient noticed that his eyes and skin have turned a yellow color. He has no past medical history of jaundice, hepatitis, blood transfusion, body piercing, tattoos or eating shellfish. He has not drink, smoke cigarettes, or use illicit drugs. He does not take any medications. He has not travelled recently. He is sexually active and is in a monogamous relationship with his girlfriend of two years who is experiencing similar symptoms. He is heterosexual and has had two previous sexual partners. He always used condoms. He received Hepatitis B vaccination prior to starting college. Patient does not have any allergies.
Past Medical History: He has no past medical history.
Surgical History: Patient denied previous surgery.
Family History: Family history is non-contributory.
Social History: Patient is a student. He denied use of tobacco, alcoholic drinks or illicit drug.
Review of the systems:
Skin: no lesion, warm to touch with yellowish discoloration.
HEENT: No headache, dizziness, no blurred vision, PERRLA, EOMI, icteric sclerae, pink conjunctivae, T-P erythematous with exudate.
Neck: posterior cervical lymph nodes swollen, tender and movable, bilaterally. Supraclavicular lymph nodes not enlarged.
Respiratory: patient denied any difficulty breathing, no cough.
Heart and lungs: Normal
Gastrointestinal: Abdomen: Normal bowel sounds, liver – 14 cm in midclavicular line by percussion, diffuse tenderness over both right and left upper quadrants on palpation. He has lost his appetite.
Genitourinary: no complaint on voiding.
Neurologic: patient is awake, alert and oriented x4, speech is clear and concise, cranial nerve intact. Normal muscle tone, no loss of sensation; deep tendon reflexes are 2/4. No deficit with motor coordination.
Musculoskeletal: no muscle aches, no pain or tenderness.
Physical examination: areas of physical examinations that are important on this patient are the following: Head and neck especially pharynx, upper palate, lymph nodes, abdomen, especially spleen. PPE: Patient is well-developed, in no acute distress. He appears concerned and anxious. With temperature of 101.4*F. tympanic. Icteric sclerae, pink conjunctivae, T-P erythematous with exudate. Neck: posterior cervical lymph nodes swollen, tender and movable, bilaterally. Supraclavicular lymph nodes not enlarged. Skin is positive for jaundice. Abdomen: Normal bowel sounds, liver – 14 cm in midclavicular line by percussion, diffuse tenderness over both right and left upper quadrants on palpation.
Primary Diagnosis: The primary considerations at this point are trep throat, viral pharyngitis an infectious mononucleosis.
Epstein-Barr virus, commonly referred to as EBV, belongs to the Herpes virus family and is one of the common human viruses. It infects people worldwide and many contract infections with EBV at some point during their lives. In childhood, EBV usually causes no symptoms or very mild brief illnesses. In adolescence and young adults, the most common primary infection caused by EBV is infectious mononucleosis, also known as the “kissing disease” due to its oral transmission McCance, & Huether, Pg. 1011. (2014).
Differential Diagnoses:
- Infectious Mononucleosis presents with the classic triad of fever, pharyngitis, and lymphadenopathy which patient is experiencing. It can be ruled in or out by doing a peripheral smear looking for the presence of atypical lymphocytes and doing a heterophile antibody test (McCance, & Huether, Pg. 1012. 2014). Management of IM is usually supportive.
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).
Screening: None
Rx: Amoxicillin 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.
References
Ebell, M. H., Call, M., Shinholser, J., & Gardner, J. (2016). Does This Patient Have InfectiousMononucleosis? The Rational Clinical Examination Systematic Review. JAMA: Journal Of The American Medical Association, 315(14), 1502-1509. doi:10.1001/jama.2016.2111
Naviglio, S., Abate, M. V., Chinello, M., & Ventura, A. (2016). Splenic Infarction in Acute Infectious Mononucleosis. Journal Of Emergency Medicine (0736-4679), 50(1), e11-e13. doi:10.1016/j.jemermed.2015.09.019
Skoog, G., Edlund, C., Giske, C. G., Mölstad, S., Norman, C., Sundvall, P., & Hedin, K. (2016). A randomized controlled study of 5 and 10 days treatment with phenoxymethylpenicillin for pharyngotonsillitis caused by streptococcus group A – a protocol study. BMC Infectious Diseases, 161-6. doi:10.1186/s12879-016-1813-7
Thompson, A. E. (2015). Infectious Mononucleosis. JAMA: Journal Of The American Medical Association, 313(11), 1180.
Infectious mononucleosis caused by Epstein barr virus and hyperbilirubinaemia: case report. (2016). Reactions Weekly, 1608(1), 46.
- In McCance, K. L., & In Huether, S. E. (2014).Pathophysiology: The biologic basis for disease in adults and children.
- McCance, K. L., & Huether, S. E. (2014). Pathophysiology: The biologic basis for disease in adults and children. St. Louis: Mosby.
McIsaac, W., Kellner, J. D., Aufricht, P., Vanjaka, A., & Low, D. (2004). Empirical validation of guidelines for the management of pharyngitis in children and adults. Journal of American Medical Association, 291(13), 1587-1595. doi: 10.1001/jama.291.13.1587
Rimoin, A., Hoff, N., Fischer Walker, C., & Hamza, H. (2011). Treatment of Streptococcal pharyngitis with once-daily Amoxicillin versus intramuscular Benzathine Penicillin in low-resource settings: a randomized controlled trial. Clinical Pediatrics, 50, 535-542. doi: 10.1177/0009922810394838
