Transcript Case 92
Case #92: Say Ahhhh! BY AMI ALANIZ Gross Overview Note the: Soft palate: general appearence Tonsil: size and general appearance The Patient Profile female 11 years old Caucasion Past Medical History Ear infections at ages 3 & 4 Chickenpox at age 6 Viral-like URI at age 9 No previous episodes of streptococcal pharyngitis or rheumatic fever Up to date immunizations Social History Attends 6th grade Plays baseball Mother and mother’s boyfriend smoke in the house The Symptoms Case Question #1 List 18 patient-specific clinical features (including signs and symptoms, medical history, findings on physical examination, and laboratory blood test results) that support a diagnosis of group A betahemolytic streptococcal pharyngitis. Case Question #2 “What is the single major risk factor for acute streptococcal pharyngitis in this case study?” Present Illness “My throat hurts and its hard to swallow. I’m cold, too.” appetite has been poor for 48 hours (steady fluid intake) “strep has been going around at her school for the past two weeks” Case Question #2: Answered Involvement in sports as well as the strep throat going around at her school. Present Illness (cont’d) appears… ill pale shivering Present Illness (cont’d) ill for three days sore throat temperature of 102.3 chills pain with swallowing Testing Terms to Know o edema o swelling o general response to injury or inflammation o erythema o redness o results from capillary congestion o exudate o a “mass of cells and fluid that seep out of blood vessels or organs” o especially prevalent in inflammation Testing, Testing! Vital Signs temperature: 103.1 F Head, Eyes, Ears, Nose, and Throat tonsillar edema and erythema with yellow-white exudate soft palate erythema prominent “strawberry” tongue Tonsilllar edema and erythema with yellow-white exudate Soft Palate Erythema (extreme!) Not a Strawberry Tongue Prominent “Strawberry” Tongue Testing, Testing (cont’d) Neck small, mobile anterior lymph nodes (tender to touch) Skin warm pale no rash Lab Results HB Hct Plt WBC 13.2 g/dL Neutrophils 43.9% Lymphocytes 390,000/mm^3 Monocytes 15,500/mm^3 Eosinophils 72% Basophils 1% 21% ESR 18 mm/hr 5% CRP 2.3 mg/dL 1% (+) Rapid streptococcal antigen test Case Question #1: Answered fever Warm skin Pale skin Absence of rash Tonsillar edema prominent “strawberry” chills tongue lack of appetite white blood cell count tiredness neutrophils possible weak immune lymphocytes system “strep has been going pain with swallowing Tonsillar erythema with around school for the past yellow-white exudate tender with palpitation two weeks” lymph nodes soft palate erythema participation in sports (presumably at school) Final Notes What is the official diagnosis? group A beta-hemolytic streptococcus pharyngitis “Bacteria are responsible for approximately 5 to 10 percent of pharyngitis cases, with group A beta-hemolytic streptococci being the most common bacterial etiology. A positive rapid antigen detection test may be considered definitive evidence for treatment; a negative test should be followed by a confirmatory throat culture when streptococcal pharyngitis is strongly suspected.” Case Question #3 “What are the drugs of choice for this patient?” penicillin cephalorsporins (like cephalexin) erythromycin-based medications clindamycin azithromycin Case Question #4 “For which type of heart disease is this patient at risk if treatment is not started?” Rheumatic fever. Sources/Citations http://www.livestrong.com/article/207279-normal-wbc-range-in-children/ http://www.itpsupport.org.uk/childhooditp.htm http://www.childrensmn.org/manuals/lab/hematology/018981.asp http://www.nlm.nih.gov/medlineplus/ency/article/003657.htm http://www.nlm.nih.gov/medlineplus/ency/article/003051.htm http://www.medicinenet.com/strep_throat_gas/page4.htm http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682733.html http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682381.html http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682399.html http://www.nlm.nih.gov/medlineplus/druginfo/meds/a697037.html