Patient name: K.M
Age: 17 years
Gender: Female
Race: Caucasian
Chief Complaint:
- Throat pain three days
- Headache and fever one day
History of Presenting Illness:
K.M is a 17-year-old female Caucasian patient who presented with a 3-day history of throat pain that was gradually worsening. Verbal pain scale 4/10. Her throat pain was aggravated by swallowing saliva, denied any relieving factors. The patient experiences an associated global but dull headache radiating to the nape of the neck, which is exacerbated by her bending but well relieved by taking acetaminophen. She also reported being having chills at night. Still, she had otherwise recorded regular temperature readings and reported persistent fatigue, joint pains, and generalized body pains that were otherwise relieved by acetaminophen—no swelling of the joints.
She denies having a runny nose, cough, or body fatigue. She also reported a body rash noted shortly after the throat pain that was rough to touch, red, and very itchy on the chest and the arms and forearms. She, however, denied having any swelling on any part of her body or of the joints.
K.M has not been around any family member or friend who has similar symptoms. She denies any outbreak of similar symptoms in school. She reports having used her boyfriend’s toothbrush by accident four weeks ago while at their home. She also admits to them frequently kissing since they started dating three months ago.
Current medication:
Acetaminophen 500mg. The medication is taken three times a day for two days to relieve joint pains and headaches (Voicu et al., 2019).
Allergies:
The patient reports no environmental, medication, or food allergies.
Past Medical History:
The patienthas had adenotonsillectomy in childhood due to recurrent throat infections. No history of surgeries. No history of admission. Immunization is up to date, and the last tetanus dose was administered to the patient at seven years.
Social history:
The patient is still in high school. She loves to play basketball and watch movies. The patient is the firstborn in a family of 3. She lives in Austin, Texas. All family members are alive and well. The patient has a boyfriend who is 17 years of age. She denies sexual debut. She also admits to having a good working and social relations with her parents and friends. She has been performing well at school.
Substance history:
K.M has never smoked cigarettes or taken alcohol. She also denies prior or current use of any non-prescription drugs or substances.
Family history:
The patient’s father has primary hypertension. Her paternal grandmother was also hypertensive. She is reported to have passed away two years ago after suffering from end-stage kidney disease. There are no other suspected chronic illnesses. Her mother and siblings are also alive and well.
Surgical history:
No history of any surgical procedures.
Mental history:
No prior mental illnesses. The patient does not suffer from anxiety or panic attacks. The patient has no social stressors. She also has no prior or current suicidal ideation and has never engaged in any self-harm.
Violence history:
No evidence of violent history.
Reproductive history:
Menarche at 13. Regular 28-day cycle.3-4 days’ normal flow menses. She uses about 3 -4 sanitary towels during the day. No dysmenorrhea. No current or past use of contraceptives. The patient has never engaged in any form of sexual intercourse.
Review of systems
General: No reports of weight loss.
Respiratory:
- No chest pains, no difficulty in breathing, or shortness of breath.
- Cardiovascular; no awareness of heartbeat, no chest pains, no palpitations.
Gastrointestinal:
- No loose stools, no abdominal pain, swelling or discomfort, no nausea or vomiting. There are reports of poor appetite.
- Genitourinary; no pain when passing urine, not foul-smelling, no urine urgency or frequency, no genital ulcers o abnormal discharge.
Physical examination
- Fair general condition goo nutritional status not pale no scleral jaundice no cyanosis good peripheral pulses no discrete no lower limb edema.
- Bp 114/65mmhg Pulse 78 reg Temp 36.6 degrees Celsius Resp rate 16 Weight 5 5kg Height 160cm BMI 21.4.
- Lymphadenopathy posterior cervical on the left about three pea-sized lymph nodes palpated each discrete tender and mobile right submandibular region about three palpated peas sized mobile non-tender no skin changes. Axillary lymphadenopathy- discrete swollen lymph nodes bilaterally left-3 palpated each less than 2 cm mobile no skin changes right-4 palpated each less than 2 cm tender mobile.
CNS:
Pupils bilaterally equal and reactive to light. Neck supple. All cranial nerves are intact.
ENT:
Hyperemic throat exudates were noted on the posterior pharynx+ uvula buccal cavity normal tympanic membranes bilaterally no inferior turbinal hypertrophy.
Skin:
The papular rash is rough to touch on the trunk, upper limbs, and thighs. The rash is red and itchy.
Abdominal:
Moving with respiration soft non-tender, no splenomegaly or hepatomegaly.
Working Diagnosis: Infectious Mononucleosis.
Infectious Mononucleosis-history of throat pain (Ebell et al., 2016), headache, fever rash, and fatigue with prior history of kissing a new partner for three months and use of his toothbrush. Presence of lymphadenopathy on physical examination.
Laboratory Investigations.
- Complete Blood Count with differential-lymphocytosis with a predominance of atypical lymphocytes.
- Heterophile antibody testing- IgM antibodies would be positive in the first few weeks of infection.
- CRP may be elevated due to the ongoing inflammation.
- Liver function tests may be deranged.
- Gonorrhea per-pharyngeal swab is positive in gonococcal pharyngitis.
- Rapid influenza diagnostic test positive in influenza pharyngitis.
Differential diagnoses
- Viral pharyngitis (other than Ebstein bar virus)-throat pain, headache, fever, fatigue. Acute onset of symptoms and presence of a generalized papular rash. Expected lymphopenia or lymphocytosis on complete blood count mild elevation in c- reactive protein.
- Bacterial pharyngitis- Presence of throat pain, headache, fever, and fatigue plus pharyngeal exudation. Expected leukocytosis or neutrophilia on complete blood count (Ebell et al., 2016). Marked elevation in c-reactive protein compared to viral infections.
- Gonococcal pharyngitis- history of throat pain, headache, fevers, and fatigue. The patient had a new partner recently. Pharyngeal exudation and tender lymphadenopathy on physical examination. Less likely diagnosis since the patient had not engaged in any form of sexual intercourse with a partner and had no abnormal vaginal discharge.
Plan.
Empiric treatment-Pharmacological
- 1. Analgesics/antipyretic-Ibuprofen 400 mg three times daily.
- 2. Mouth gargle ten mills eight hourly-gargle and spit and throat lozenges (to soothe throat).
Patient Education.
- The therapy mainly consists of hydration, rest, and analgesia. Most cases of infectious mononucleosis resolve with supportive treatment, but symptoms may last for several weeks or months.
- Excessive physical activity/contact sports should be avoided during the first weeks of disease, as splenic rupture may occur even with no evidence of splenomegaly at the time of diagnosis. Splenic enlargement can occur at any time of the disease process.
- The patient is advised to take adequate rest and hydration.
- The patient cautioned against sharing personal items, e.g., spoons and toothbrushes.
- Avoid using over-the-counter antibiotics (Thompson & Ramos, 2016).
- Present to the hospital for review in case of persistence of symptoms or no improvement.
References
Ebell, M. H., Call, M., Shinholser, J., & Gardner, J. (2016). Does this patient have infectious mononucleosis? JAMA, 315(14), 1502. https://doi.org/10.1001/jama.2016.2111
Thompson, D. F., & Ramos, C. L. (2016). Antibiotic-induced rash in patients with infectious mononucleosis. Annals of Pharmacotherapy, 51(2), 154-162. https://doi.org/10.1177/1060028016669525
Voicu, V. A., Mircioiu, C., Plesa, C., Jinga, M., Balaban, V., Sandulovici, R., Costache, A. M., Anuta, V., & Mircioiu, I. (2019). undefined. Frontiers in Pharmacology, 10. https://doi.org/10.3389/fphar.2019.00607
Leave a Reply