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PhyAssCaseStudy1.1.docxCASE STUDY: INFECTIOUS MONONUCLIOSIS 2
CASE STUDY: INFECTIOUS MONONUCLIOSIS 6
Case Study: Infectious Mononucleosis
Running head: CASE STUDY: Infectious Mononucleosis 1
Case Study: Infectious Mononucleosis
Patient Information: “S.J. is a 17-year-old, Male, Caucasian” ("Patient Information," 2017, p. 1).
History of Present Illness: “Patient is a 17-year old male, brought in by mother for sore throat. Symptoms started 2 days ago with increasing severity. Patient describes pain as 9/10 on pain scale, associated with difficulty swallowing, hoarseness accompanied with headache, some body weakness and a fever with maximum reading of 101.9 degrees Fahrenheit. It is made worse with eating and trying to swallow food. He has tried drinking warm lemon juice affording some throat relief. He has also been taking Tylenol affording resolution of the fever.
Patient reported he was exposed to his classmate with similar symptoms 1 day before the appearance of his symptoms” ("Patient Information," 2017, p. 1).
Allergies: “No known drug and food allergies” ("Patient Information," 2017, p. 1).
Past Medical History: “Patient denied any previous hospitalization” ("Patient Information," 2017, p. 1).
Surgical History: “Patient denies any previous surgery” ("Patient Information," 2017, p. 1).
Family History: “Family history is non-contributory” ("Patient Information," 2017, p. 1).
Social History: “S.J. is a high school student, denies use of alcohol drinks, tobacco or illicit drug use” ("Patient Information," 2017, p. 1).
Sexual History: “Sexually active; in a monogamous relationship” ("Patient Information," 2017, p. 1).
Review of Systems:
HEENT
(+) headache, no vertigo, dizziness or lightheadedness, no blurring of vision, no double vision, no tearing, (+) sore throat, dysphagia, hoarseness, no ringing in the ears, (+) ear pain bilaterally, worst with swallowing, no neck pain” ("Patient Information," 2017, p. 1).
PE findings
“Significant for throat findings i.e., pharyngeal walls pink, (3+) size tonsils, cherry red, and swollen with yellowish exudate. Additionally, patient has enlarged cervical lymph nodes bilaterally” ("Patient Information," 2017, p. 1).
“Other ROS and PE findings are unremarkable” ("Patient Information," 2017, p. 1).
Assessment
Primary Diagnosis
S.J.’s clinical findings are suggestive of Infectious Mononucleosis. IM can be spread by sharing utensils, kissing, and droplets (Ebell, 2016). Epstein-Barr virus is most often the cause, and as such, it cannot be cured with antibiotics (Ebell, 2016). IM is also called the kissing disease typically caused by Epstein-Barr virus (EBV). EBV usually presents with fever, pharyngitis, and lymphadenopathy (Ebell, 2016). In addition to those symptoms, there may be hepatomegaly, rash, and hepatic dysfunction (Ebell, 2016). Unexplained elevated temperature persisting more than 2 weeks, abnormal liver function test, hepatomegaly, and jaundice, indicate EBV infection (McCance & Huether, 2016, p.1018). This patient has the classic triad of IM and but is early in the disease and hepatomegaly would not be present yet. IM is most commonly seen in children to young adults (Ebell, 2016). Classic characteristics of IM are “sore throat, fever, headache,” and generalized weakness (Ebell, 2016, p. 2). Other common symptoms are swollen cervical lymph nodes, swollen and red tonsils that may or may not have exudate (Ebell, 2016). A late sign, and also not as common, is enlarged spleen. IM is a viral infection, typically caused by the Epstein-Barr virus, and it infects the B cells, which enables the virus to become systemic via the blood stream (McCance, Huether, Brashers, & Rote, 2016). Most people have healthy immune systems and their bodies will make “IgG, IgM, and IgA” antibodies to fight the virus (McCance, Huether, Brashers, & Rote, 2016, p. 1018). To help the body ward off the EBV, T cells are released, and cause the swelling of the “lymph nodes, tonsils, and spleen” (McCance, Huether, Brashers, & Rote, 2016, p. 1018). S.J is in the age group that IM is most common in, and has a girlfriend (kissing), and also was possibly exposed to droplets from a classmate. Of the common symptoms, S.J. has; sore throat, fever, headache, body weakness, dysphagia, bilateral “enlarged cervical lymph nodes,” red-swollen tonsils with yellowish exudate, which would explain the ear pain, while swallowing, and dysphagia ("Patient Information," 2017, p. 1). IM closely resembles Streptococcus infection of the throat, and tonsillitis, but can be differentiated with a blood test looking for a high percentage of lymphocytes, specifically atypical lymphocytes (Ebell, 2016). Also, a monospot test can be done to check for antibodies are made by the lymphocytes to counteract the infection (Ebell, 2016). These tests may have a false negative reading at early onset of the virus. IM usually is self-resolving, and requires sufficient rest to recover, unless it coincides with a strep infection, which would require antibiotics. A proper diagnosis of IM is very important, because spleen rupture is possible if the patient has impact to the abdominal area, therefor impact sports should be avoided.
Differential Diagnosis
1. Group A beta-hemolytic Streptococcus Pharyngitis (Strep Throat) – Targets late teens and children, which places S.J. at risk. Clinical presentation of Strep Throat is typically, “severe sore throat, painful swallowing, and fever” along with possible tonsil, uvula, and pharyngeal erythema, swollen cervical lymph nodes, and tonsillar exudate (Hoyle, 2016, p. 47). Other signs can be red spots on the roof of the mouth, and epidermal rash (Hoyle, 2016). Diagnosis can be ruled out with a Rapid antigen test which results in minutes, or a throat culture which results in 48 hours (Hoyle, 2016). Rash and red spots on throat are not present in S.J., and S.J. also presents with body weakness that is suggestive on IM ("Patient Information," 2017) (Ebell, 2016).
2. Viral Pharyngitis – Viral Pharyngitis is very common and easily transmitted. Classic symptoms of VP are erythema of throat, “conjunctivitis, malaise, or fatigue, and a low-grade fever” (Vincent, Celestine, & Hussain, 2014, p. 1465). The tonsillar exudate present in S.J. are more typical in Strep Throat, and IM. VP is self-limiting and usually lasts one to two weeks.
PLAN
Diagnostic
A rapid antigen test can rule out Strep Throat quickly. A Monospot test can confirm present of Epstein-Barr virus (the typical cause of IM), which can be cross confirmed with a blood smear test if those results have lymphocytes greater that 50% (McCance, Huether, Brashers, & Rote, 2016). If rapid antigen test is positive, IM cannot be completely ruled out, because a person can have both IM and Strep Throat at the same time.
Medical Treatment
If rapid antigen test is positive, treat with Penicillin 250 mg by mouth three times daily for 10 days. Do not treat with antibiotics if there is no bacterial infection. Treatment for IM alone is rest, hydration, and Tylenol or Motrin for fever and body aches, and lozenges or throat spray may be used.
Screening
None
Education/Home Remedies
If antibiotics prescribed, finish entire antibiotic regime unless severe allergic reaction occurs, in that case, call 911 immediately. Do not take with acidic fruit juice, or within 1 hour of consuming acidic fruit juice. Monitor for gastric upset and diarrhea, and rash (Vallerand & Sanoski, 2017). Over the counter throat lozenges and tea with lemon and honey for throat pain. Tylenol or Motrin for pain and fever. These can be alternated for maximum pain and fever control. Change toothbrush after day 3 of antibiotics, and wash linens on sterile cycle weekly. Wash hands frequently, and instruct family to do the same.
Consult/Referral
If taking antibiotics, monitor for signs and symptoms of anaphylaxis, such as difficulty breathing, coughing, wheezing, increased fever, pain or tightness in chest. If any of these symptoms occur, call 911 immediately. If symptoms worsen, or if abdominal pain is experienced call health care provider.
References
Case Study 1. (2017). Retrieved from https://cdrewu.blackboard.com/webapps/blackboard/execute/announcement?method=search&context=mybb&course_id=_299234_1&individualAnnouncementId=_13306_1
Ebell, M. E. (2016, April 12). Infectious Mononucleosis. Journal of American Medical Association. https://doi.org/10.1001/jama.2016.2474
Hoyle, C. (2016). Make your strep diagnosis spot on. The Nurse Practitioner, 34(10), 46-52. https://doi.org/10.1097.NPR.0000361.11273.5c
McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2016). Pathophysiology: The biologic basis for disease in adults and children (7 ed.). Maryland Heights, MO: Mosby Elsevier.
Vallerand, A. H., & Sanoski, C. A. (2017). Davis’s Drug Guide for Nurses (15th ed.). Philadelphia, PA.: F. A. Davis Company.
Vincent, M. T., Celestine, N., & Hussain, A. N. (2014). Pharyngitis. American Family Physician, 1464-1470. Retrieved from http://www.aafp.org/afp/2014/0315.p1465.html
