Case Study #1

· Immunization: Age-appropriate Up-to-date vaccinations according to the immunization registry.

· Screening test: Skin lesion biopsy at age 30.

PSYCHOSOCIAL

Julie is married and has a 3-year-old son. Nonsmoker, she drinks wine socially; admitting to 2-3 glasses a few nights a week. Julie works as a receptionist at a car dealership. She is an avid outdoor enthusiast. She hikes regularly and tries to travel when she can to tropical locations. Her last trip was a few weeks ago. She traveled by airplane to Puerto Rico.

FAMILY HISTORY

Mother (65-Year-old) alive with HTN, HLD, CVA, Father (68 years old) alive with CAD, HTN, HLD, DM, Husband (39 years old) alive with HTN, Son (3 years old) alive with asthma

REVIEW OF SYSTEMS

Skin: Denies rashes, lumps, sores, itching, dryness, and color change. Denies changes in hair or nails, changes in size or color moles.

HEENT (Head, Eyes, Ears, Nose, and Throat):

Head: Denies headache, head injury, dizziness, lightheadedness . Eyes: Denies changes in Vision, glasses or contact lenses, denies pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Denies changes in hearing, Tinnitus, Vertigo, earaches, infection, discharge. Nose, and sinuses: Denies frequent colds, nasal stuffiness, discharge, or itching, hay fever, denies nose- bleeds, sinus trouble. Throat: (or mouth and Pharynx): denies bleeding gums, sore tongue, dry mouth, hoarseness, endorses sore throats, endorses redness on the back of her throat.

Neck: Denies Swollen Glands, goiter, lumps, pain, or stiffness in the neck.

Breast: Denies Lumps, pain, or discomfort, nipple discharge.

Respiratory: endorses "occasional cough". Denies sputum, hemoptysis, denies shortness of breath (dyspnea) wheezing, pain with deep breath (pleuritic pain).

Cardiovascular: endorses high blood pressure. denies rheumatic fever or heart murmurs, denies chest pain, denies palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea) swelling in the hands , ankles, or feet (edema).

Gastrointestinal: denies low appetite. endorses difficulty swallowing, denies heartburn, nausea, denies changes in bowel movements, stool color and size, change bowel habits, denies pain with defecation, rectal bleeding, black or tarry stools, hemorrhoids, constipation, diarrhea. Denies abdominal pain, food intolerance, excessive belching or passing of gas. Denies yellowing of the skin sclera (Jaundice), liver, or gallbladder trouble.

Peripheral Vascular: Denies. Intermittent leg pain with exertion (Claudication); leg cramps; varicose veins; past clots in the veins; selling in claves, legs, or feet; color change in fingertips or toes during cold weather; selling with redness or tenderness.

Genital: Denies abnormal menstrual irregularity, monthly frequency, 3-5 days in duration of periods, normal amount of bleeding; denies bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension, denies Vaginal discharge, itching, sores, lumps, sexually transmitted infection, and treatments. Sexual interest, satisfaction, denies pain during intercourse (dyspareunia)

Musculoskeletal: Denies Muscle or joint pain, stiffness, arthritis, gout, backache. Denies Neck or low back pain or Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness.

Psychiatric: Denies nervousness, tension, mood disorders, including depression, denies memory change, suicidal ideation, suicide plans or attempts.

Neurologic: denies Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness, loss of sensation, tingling or “pins and needles,” ( Paresthesia) tremors or other involuntary movement seizures.

Hematologic: Denies Anemia, easy bruising, or bleeding

Endocrine: Denies Heat or cold intolerance, excessive sweating ,excessive thirst (polydipsia), hunger (polyphagia), or urine output (polyuria).

PHYSICAL EXAMINATION

Neck: Neck supple. Trachea midline. Thyroid without nodule or goiter

Lymph nodes: Bilateral cervical lymphadenopathy noted to palpation., No axillary, or epitrochlear nodes.

Thorax and lungs: Posterior thorax elliptical in shape, symmetrical with good excursion , no rashes or lesions noted, skin is intact, anterior-posterior (A/P) diameter is 2:1, chest wall without pain to palpation, Tactile fremitus is negative, Lungs resonant on percussion. Breath sounds vesicular with no added sounds to auscultation, No egophony, bronchophony, or whispered pectoriloquy. Diaphragms descend 4 cm bilaterally to level of cervical vertebrae 8(C8) anteriorly, to thoracic vertebrae 10 (T10) posteriorly.

Cardiovascular: Jugular venous pressure 1 cm above the sternal angle, with the head of the examining table raised to 30 degrees. Carotid upstrokes brisk, without bruits. Point of maximal impulse discrete and tapping, barely palpable in the 5th left interspace, 8 cm lateral to the midsternal line. Good S1, S2. No murmur auscultated, no splitting of S3 or S4, No orthopnea, palpitations, or dyspnea.

Breasts: Pendulous, symmetric. No masses; nipples without discharge.

Abdomen: soft, nontender to palpation, stomach tympanic to percussion, Bowel sounds active x 4. No tenderness or palpable masses. Liver span 7cm in right midclavicular line; edge smooth, palpable 1 cm below right costal margin (RCM). no Splenomegaly. No costovertebral angles tenderness (CVAT).

Genitalia: External genitalia without lesions. Mild cystocele at introitus on straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge. Uterus anterior, midline, smooth, not enlarged . Adnexa is not palpated due to obesity and poor relaxation. No cervical or Adnexal tenderness. Pap Smear taken. Rectovaginal wall intact.

Extremities: Bilateral upper extremities warm. Bilateral lower extremities; no edema. Calves supple, symmetric, temperature intact bilaterally with negative Homan's sign.

_________________________________________________________        

Radial           Femoral      Popliteal       Dorsalis Pedis    Posterior Tibial

_________________________________________________________

Rt              2+                  2+                2+                      2+                       2+

_________________________________________________________ LT              2+                 2+                2+                       2+                      2+

_________________________________________________________

Musculoskeletal: No joint deformities or selling on inspection and palpation. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles.

Neurologic: Mental Status:  Alert and cooperative. Thought processes are coherent and insight is good. Oriented to person, place, and time. Cranial nerves: II to XII intact. Motor: Good muscle bulk and tone. Strength: 5/5 bilaterally in deltoids, biceps, triceps, hand grips, iliopsoas, hamstrings, quadriceps, tibialis anterior, and gastrocnemius. Cerebellar: Rapid Alternating movements (RAMs)  and point-to-point movements intact. Gait stable, fluid. Sensory:  Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative.

DIFFERENTIAL DIAGNOSIS

Diagnosis #1: Bacterial pharyngitis

Pathophysiology: With the aid of adhesins on the organism's surface, bacteria adhere to the pharyngeal mucosa in the pathogenesis of GAS in the throat. It then produces several proteases and cytolysins, which penetrate the mucosal tissue and cause inflammation that manifests as pharyngitis symptoms such as fever, exudates, swelling, and pain with swallowing (Wolford et al., 2018).

Etiology: Bacterial pharyngitis is an infection of the oropharynx caused by S. pyogenes. which is transmitted via ingestion or airborne transmission.

Diagnostic criteria: Diagnostic evaluation of bacterial pharyngitis is done by either rapid antigen detection test or a throat culture (Luo et al., 2019).

Throat culture continues to be the gold standard for the diagnosis of streptococcal pharyngitis. Under ideal conditions, the sensitivity of throat culture for group A beta-hemolytic streptococci.

A rapid antigen detection test (rapid strep test) can be completed in the office setting, with results accessible within five to ten minutes.

Unusual Clinical findings: sore throat, temperature greater than 100.4°F (38°C), tonsillar exudates, Cough, pain when swallowing, edematous vulva, tonsillar hypertrophy and inflammation, swollen pharynx, and cervical lymphadenopathy.

Pertinent positives:

· Positive: Fever, sore throat, tender anterior cervical adenopathy, pain with swallowing, pharyngeal tonsillar exudate

Pertinent negatives:

· Negative: splenomegaly, transient upper lid edema (Hoagland sign), sandpaper rash, flushed face with circumoral pallor.

Treatment Plan: Pharyngitis; penicillin or amoxicillin are the recommended treatments. Clindamycin, clarithromycin, or azithromycin can be used for people who are allergic to penicillin. Only in specific patient populations is a test of cure advised; it should not be used frequently (Ashurst & Edgerley-Gibb, 2022).

Plan of care

Pharmacology

· Penicillin V potassium, 250 mg orally, three times a day for 10 days

· Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to lower the fever and provide pain relief for the sore throat, as needed

· Albuterol 2.5 mg via nebulizer as needed

Non-pharmacology

· Recommend that patient follow a good hand hygiene, wash hands before/ after handling food or touching face

· Recommend that patient avoid sick contact, and crowed place; if necessary, cover nose and mouth with a mask.

· Encourage patients to take a few days off from work and have a good rest

· Perform either a rapid antigen detection test (RADT) or throat culture as indicated

· Encourage hydration.

Patient Education.

Patients with streptococcal pharyngitis are considered contagious until they have been taking an antibiotic for 24 hours

Educating patients to rinse toothbrushes and removable orthodontic appliances thoroughly can help to prevent recurrent infections.

Educate patients to complete the whole dose of antibiotic even if they feel better.

Follow up

· Routine post-treatment throat cultures are not necessary. About 5 to 12 percent of treated patients have a positive post-treatment culture, regardless of the therapy given (Hayes & Williams, 2022).

· Patient may return to clinic if pharyngitis is not resolve or exceed 10 days or with other severe compilations (Otitis media, post-streptococcal glomerulonephritis, rheumatic fever).

Diagnosis #2: Tonsillitis

Pathophysiology and Etiology: Tonsillitis is an inflammation of the pharyngeal tonsils. Inflammation can also affect other areas of the back of the throat, including the adenoids and the lingual tonsils. When a bacterial or viral disease invades the tonsils and causes an inflammatory reaction, tonsillitis results (Anderson & Paterek, 2022). It manifests as a result of viruses invading the tonsils, which trigger an inflammatory reaction with elevated cytokines which results in symptoms such as Sore throat, pain on swallowing, Fever, tonsillar exudate, and cough (Bakar, 2018).

Diagnosis #2: Infectious mononucleosis

Pathophysiology and Etiology: Atypical lymphocytes are mostly produced by CD8+ T cells that react to the infection. Following primary infection, EBV is permanently present in the host, particularly in B cells, and periodically sheds asymptomatically from the oropharynx (Mohseni, et al., 2022). The human herpesvirus type 4 Epstein-Barr virus (EBV) is the cause of infectious mononucleosis, which is characterized by tiredness, fever, pharyngitis, and lymphadenopathy. Rarely, severe side effects such airway blockage, splenic burst, and neurologic disorders develop. infection is unusually long, lasting around six weeks. Diagnosis is typically done by heterophile antibody tests and/or EBV-specific antibody tests (Dunmire et al., 2018).

ADDITIONAL HISTORY DATA TO SUPPORT PRIMARY DIAGNOSIS

1.Do you have any breathing problems?- The germs that cause infectious pharyngitis can generate a local inflammatory response that might cause airway blockage.

2. do you often feel tired and exhausted?- bacterial pharyngitis may make a person feel tired and exhausted often

3. do you experience any abdominal pain of feeling nauseated or vomit?- these are common symptoms of Pharyngitis.

4. have you found yourself among crowds of people recently?-.Pharyngitis can be acquired in crowdy areas.

5. did you eat anything you have not eaten before in the past week?- sometimes pharyngitis occurs because of mishandling of food.

6. did you come in contact with a person known to have sore throats recently?- pharyngitis can be acquired through personal contact.

7. have you experienced symptoms of conjunctivitis or a runny nose?- these are also additional symptoms of Group Pharyngitis

8. do you experience body aches?- with Pharyngitis it is common to have body aches

9. does your body shake and feel extremely cold?- Pharyngitis can also cause extreme colds,

10. has your appetite changed recently?- loss of appetite is also common due to viral infection

ADDITIONAL PHYSICAL COMPONENTS TO SUPPORT PRIMARY DIAGNOSIS

· Fatigue- a patient with Pharyngitis often experiences general fatigue

· Lymphadenopathy on palpation- pharyngitis is also associated with cervical lymphadenopathy

· tongue with strawberry patches- palatal petechiae is associated with this sign and is common with Pharyngitis.

· problem with swallowing due to pain and does not improve even with medication- Pharyngitis is associated with a persistent sore throat.

· Sore throat is a typical symptom of Group A streptococcal pharyngitis

Mother -65, Alive, HTN,HLD,CVA