Pediatric - Week 2 Clinical Case Report SOAP NARRATE PowerPoint
lisaberdinassi33
NSG6435_W2_SOAP.pptxInfectious Mononucleosis
Jane Doe
NSG6435 Family Health - Pediatric
7/19/2022
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Infectious Mononucleosis
Chief Complaint
A 17-year-old student present with the complaint of fever, sore throat, and malaise that has been their for several days. She present with a new rash that is developed today (Baros et al., 2019).
A 17-year-old student present with the complaint of fever, sore throat, and malaise that has been their for several days. She present with a new rash that is developed today.
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HPI
The patient is having worsened sore throat, fever, malaise, and new rashes (location) that has been therefore for several days with todays’ development of the new rash (Onset) and four day ago, he had a temperature of 103 F that has persisted (duration). The sore throat has worsened and having difficulty swallowing solid foods and drinking well (character). The sore throat becomes worse as she tries to swallow or drinks (aggravating). She has been taking oral contraceptives on the daily basis and amoxicillin yesterday (alleviating) and helps with the severe sore throat. The sore throat becomes worse with swallowing and drinking (radiation). He rates the pain as a 6/10 on the pain scale(severity). She reports mild supraorbital edema, bilateral enlarged tonsils coated with gray exudate (temporal).
The patient is having worsened sore throat, fever, malaise, and new rashes (location) that has been therefore for several days with todays’ development of the new rash (Onset) and four day ago, he had a temperature of 103 F that has persisted (duration). The sore throat has worsened and having difficulty swallowing solid foods and drinking well (character). The sore throat becomes worse as she tries to swallow or drinks (aggravating). She has been taking oral contraceptives on the daily basis and amoxicillin yesterday (alleviating) and helps with the severe sore throat. The sore throat becomes worse with swallowing and drinking (radiation). He rates the pain as a 6/10 on the pain scale(severity). She reports mild supraorbital edema, bilateral enlarged tonsils coated with gray exudate (temporal).
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Medical History
Worsened sore throat
Difficulty swallowing solid foods
Based on the case scenario presented, the patient had worsened sore throat and difficulty in swallowing solid foods.
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Medication History
Daily oral contraceptive that is not mentioned
Amoxicillin
There were some drugs that were used by the patient to help in the reduction of symptoms such as sore throat. Therefore, she took oral contraceptives daily. She also took two doses of amoxicillin yesterday before reporting to the facility.
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Family Medical History Summary
Father- no history provided
Mother- no history provided
Sister- no history provided
Paternal Grandfather- no history provided
Paternal Grandmother – no history provided
Maternal Grandmother- no history provided
Paternal Grandfather- no history provided
Based on the history of the patient in the case study, there is no any evidence that can be associated with the family history.
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Social History
Marital status-Unknown
Relationship status-unknown
Substance use-unknown
Alcohol use-unknown
The patient is a 17-year-old but the case study does not provide history about the patient relationship status. There no clear information about the substance or alcohol use about this patient. The case study also lacks information concerning the likes and dislikes of the patient and where she spend most of her time when she is free especially during weekends.
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Patient Profile
The patient is a 17-year-old
Has the ability to perform the activity of the daily living
She is able to perform the activities without any form of help
Presented herself to the facility for the medical services.
Reports about the medication she used in the past prior to the presentation to the clinic (Baros et al., 2019).
The patient is a 17-year-old and has the ability to perform the activity of the daily living without any form of help. She presented herself to the facility for the medication services. She is able to report about the medication she used in the past prior to the presentation to the clinic.
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Review of Systems
Constitutional: admits malaise and fever. Denies night sweats, fatigue, and lethargy
HEENT: denies vision changes, pain of the eye, eye discharges. Denies running nose, epistaxis, sinus pain, ear pain, odynophagia, and congestion. Admits sore throat
Breasts: denies breast pain, lumps, and discharges.
Cardiovascular: denies chest pain and palpitations
Gastrointestinal: denies abdominal pain, nausea, vomiting, diarrhea, constipation, and hematemesis
Genitourinary: denies frequent, urge, dysuria, hematuria, obstructive symptoms, discharges, pain, or bleeding
Based on the information provided by the patient, she admits to be having malaise and fever. She denies experiencing night sweats, fatigue, and lethargy. She also denies changes in the vision, eye pain, eye discharges, running nose, epistaxis, sinus pain, ear pain, odynophagia, and congestion. She admits having sore throat. She denies breast pain, lumps, and discharges.
She report no chest pain and palpitations, abdominal pain, nausea, vomiting, diarrhea, constipation, hematemesis, denies frequent, urge, dysuria, hematuria, obstructive symptoms, discharges, pain, or bleeding
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Cont’d
Musculoskeletal: denies joint pain, swelling.
Neurological: denies seizure, syncope, confusion, neck pain, weaknesses, and headache.
Psychiatric: denies confusion
Skin: admits the presence of rashes
Endocrine: denies weight loss, polyuria, polydipsia, and polyphagia
Hematologic: denies excessive bleeding, petechiae, purpura, and anemia
Allergic and Immunologic: denies the presence of swelling or pruritus
She denies joint pain, swelling, seizure, syncope, confusion, neck pain, weaknesses, and headache. She reports no confusion, admits the presence of rashes, weight loss, polyuria, polydipsia, and polyphagia. She denies excessive bleeding, petechiae, purpura, anemia, swelling or pruritus,
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Physical Examination
Vital signs: Temp: 102.2 o F, B/P 130/80, HR 105, RR 20, Ht 64’’, Weight 120 pounds
Mild supraorbital edema
Bilateral enlarged tonsils coated with gray exudate
Few petechiae on palate and uvula
Bilateral posterior cervical lymphadenopathy
Spleen palpable 3 cm below the coastal margin
The physical examination reveals that the patient has a temperature of 102.2 o F, B/P 130/80, HR 105, RR 20, Ht 64’’, Weight 120 pounds. The patient has mild supraorbital edema bilateral enlarged tonsils coated with gray exudate. The patient also has few petechiae on palate and uvula. There is bilateral posterior cervical lymphadenopathy and a spleen palpable 3 cm below the coastal margin
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Laboratory or Diagnostic Examination Outcomes
White blood cell (WBC): 17,000 cells/mm3
Lymphocytes: 50 percent
Atypical lymphocytes: 15 percent
Platelet count: 100,000/mm3 (Baros et al., 2019)
White blood cell (WBC) count of 17,000 cells/mm3 with 50% lymphocytes, 15% atypical lymphocytes, and a platelet count of 100,000/mm3.
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Risk Factors for Infectious Mononucleosis
Sharing drinks, toothbrushes, and anything that touches saliva or mouth
Sexual contact
Blood transfusion
Organ transplant
Compromised immune system that exposes individuals to EBV or viral infection that reactivates and cause second bout of the monomnucleosis (Rostgaard et al., 2019)
There are various factors that are linked to the increase in the risk of infectious mononucleosis. Some of the risks include sharing of the drinks, toothbrushes, and anything that touches on the mouth and saliva. There is also sexual contact, blood transfusion, compromised immune system that exposes individuals to develop EBV and the virus reactivating and causing second bout of mono.
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Cont’d
Diagnosis and differential diagnosis
Primary diagnosis:
Infectious mononucleosis (B27.90): the condition is characterized with extreme tiredness, high fever, headache, body aches and muscle weakness, red or sore throat, rashes, and swollen glands.
Differential diagnosis:
Cytomegalovirus (B25.9): the condition present in the form of high temperature, aching muscles, tiredness, skin rashes, sore throat, and the feeling of sickness.
The condition is ruled out since the patient never reported longer duration of temperature (Ishii et al., 2019).
Infectious mononucleosis (B27.90): the key symptoms include extreme tiredness, high fever, headache, body aches and muscle weakness, red or sore throat, rashes, and swollen glands.
Differential diagnosis: Cytomegalovirus (B25.9): the common features of this condition include high temperature, aching muscles, tiredness, skin rashes, sore throat, and the feeling of sickness.
The condition is ruled out since the patient never reported longer duration of temperature
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Cont’d
Human immunodeficiency virus (HIV) (B20): characterized with fever, chills, rashes, night sweats, muscle aches, sore throat, fatigue, and swollen lymph nodes. Ruled out since the patient never had chills
Human herpesvirus type 6 (B10.81): the disease is characterized with sudden high fever that lasts for three days, running nose, coughing, mild diarrhea, swollen lymph node within the neck, irritability, and reduction in appetite.
The condition is ruled out since the patient never presented running nose, diarrhea, coughing, and reduced in appetite (Ishii et al., 2019)
It is also likely that the patient might be having HIV and the common symptoms include fever, chills, rashes, night sweats, muscle aches, sore throat, fatigue, and swollen lymph nodes. However, it is ruled out since the patient never had chills. Another potential condition is human herpesvirus type that has symptoms of sudden high fever that lasts for three days, running nose, coughing, mild diarrhea, swollen lymph node within the neck, irritability, and reduction in appetite. Nevertheless, the condition is ruled out since the patient never presented running nose, diarrhea, coughing, and reduced in appetite.
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Cont’d
Treatment
Management using pain relievers and fever reducers
These medications include ibuprofen and acetaminophen is used.
Home remedy using salt water gargles
The salt water gargles are used for sore throat.
Patient to take rest
Avoid sports until symptoms disappear.
This disease is a virus, therefore it cannot be treated using antibiotics. Therefore the management of the symptoms is done using pain relievers and fever reducers, in this case medications like ibuprofen and acetaminophen is used. Home remedy can include salt water gargles for the sore throat. The patient can be advised to rest and avoid sports until the symptoms disappears.
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Cont’d
Teaching and Health Promotion
Health promotion practices is important in the management of this condition.
Patient is advised to wash hands after bathrooms and after eating.
Patient informed to cough or sneeze into sleeve or tissue
She is advised to wash hands after sneezing and coughing.
Patient informed to avoid individuals with this condition or symptoms of this disease
She is advised to stay home from work or school in case she develops the symptoms again.
She is advised not to share objects that comes into contact with the mouth (Poorebrahim et al., 2017).
The management of this condition requires health promotion practices. Therefore, the patient is advised to wash hands after using bathrooms and after eating. The patient is advised to cough or sneeze into sleeve or tissue and wash hands afterward. The patient is advised to avoid individuals with this condition or symptoms associated with mononucleosis until they recover. The patient is advised to stay home from work or school in case they have symptoms. The patient is advised not to share objects that comes into contact with the mouth.
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Cont’d
The patient is also advised to care for the rashes.
Advised to avoid harsh soaps and detergents.
Advised to avoid perfumed soaps or lotions.
Patient informed to use antihistamine or steroid cream to help with rashes
Avoid strenuous activities for 3 weeks
The patient is also advised to care for the rashes. She is advised to avoid harsh soaps and detergents. She is also advised to avoid perfumed soaps or lotions. She is advised to use antihistamine or steroid cream to help the situation she is advised to refrain from strenuous activities for the first 3 weeks
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Follow-up
The patient followed for the medication adherence.
Patient return to the facility after 14 days
This helps in monitoring the potential changes in the symptoms.
The scheduled routine visits help in monitoring the course of illness
It also helps in detection of potential complications.
Follow-up done to give medical clearance for the resumption of strenuous activities
A follow-up is plan for sonographic diagnosis.
The patient is followed for the medication adherence. She is advised to return to the facility after 14 days to help in monitoring the potential changes in the symptoms. The schedule routine visits with the healthcare provider is doe to help in monitoring the course of illness and detection of potential complications. The follow-up is done to give medical clearance for the resumption of strenuous activities or contract sports. A follow-up is plan for sonographic diagnosis.
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References
Barros, M. H. M., Vera-Lozada, G., Segges, P., Hassan, R., & Niedobitek, G. (2019). Revisiting the tissue microenvironment of infectious mononucleosis: identification of EBV infection in T cells and deep characterization of immune profiles. Frontiers in immunology, 10, 146.
Ishii, T., Sasaki, Y., Maeda, T., Komatsu, F., Suzuki, T., & Urita, Y. (2019). Clinical differentiation of infectious mononucleosis that is caused by Epstein-Barr virus or cytomegalovirus: A single-center case-control study in Japan. Journal of Infection and Chemotherapy, 25(6), 431-436. Doi: 10.1016/j.jiac.2019.01.012
Poorebrahim, M., Salarian, A., Najafi, S., Abazari, M. F., Aleagha, M. N., Dadras, M. N., ... & Poortahmasebi, V. (2017). Regulatory network analysis of Epstein-Barr virus identifies functional modules and hub genes involved in infectious mononucleosis. Archives of virology, 162(5), 1299-1309.
Rostgaard, K., Balfour Jr, H. H., Jarrett, R., Erikstrup, C., Pedersen, O., Ullum, H., ... & Hjalgrim, H. (2019). Primary Epstein-Barr virus infection with and without infectious mononucleosis. PloS one, 14(12), e0226436.
