Transcript Case Presentation- Infectious Mononucelosisx

Friday, September 3rd 2010
Jody P.
15 year-old female
Overview: The History and Physical
• Subjective
– Chief Complaint
– History of Chief
Complaint
– Past Medical
History
• Medications
• Allergies
– Social History
– Family History
– Review of
Systems
• Objective
– Vital Signs
– Physical exam
• Assessment
– Problem List
– Differential Diagnoses
– Diagnosis
• Plan
– Lab Tests
– Treatments
Subjective: Chief Complaint
• “I’m here with my mom for my sports
physical. She is in the waiting
room.”
Subjective: History of Chief Complaint
• “I am on the tennis team. I have
played on the team for the past 2
years. I think I am pretty healthy
except for a recent cold. I was seen
in an urgent care 2 weeks ago, they
said I had strep throat even though
the swab test was negative.”
Subjective:
• When asking Jody about her past
medical history, health-influencing
behaviors, family and social history,
she tells you:
Subjective:
• “I had chicken pox when I was 5. I don’t think
I’ve had any shots since I was a baby. I’m not
allergic to any medicines, but I did just finish
some antibiotic for my throat. I have never been
to the hospital or had surgery or anything like
that, and I workout for tennis a lot and eat well.
My family is healthy, but my dad has high blood
pressure. I do drink alcohol sometimes on the
weekends, but everyone does here in Athens.
My boyfriend and I have had sex a few times, but
most of the time we use a condom…wait, you
don’t have to tell my mom about that last part, do
you?”
Subjective: Review of Systems
• Negative, except as noted below:
– General: “I’ve been pretty tired lately,
but maybe it’s because tennis
conditioning has been tough.”
– HEENT: “I finished all of that antibiotic I
told you about, but my throat still hurts.”
What should be the first piece of
information in your objective section?
1. Medications the
patient is taking
2. Recent lab values
3. The patient’s general
appearance
4. Vital signs
5. Your assessment
and plan
Objective: Vital Signs
Height:
Weight:
Temperature:
Pulse:
Respirations:
Blood Pressure:
64 inches
119 lbs
100.4˚ F ( 38 C)
90 bpm
16 rpm
100/60 mmHg
Which of Jody’s vital signs is
abnormal?
1. Blood pressure
(100/60 mmHg)
2. Pulse (90 bpm)
3. Respiratory rate
(16 rpm)
4. Temperature
(100.4˚ F/38 C)
Objective: Fever
• Different sources give different
parameters
• Elevation of body temperature that
exceeds the normal daily variation
and
• Occurs in conjunction with an
increase in the hypothalamic set
point (e.g., from 37°C to 39°C)*
*Harrison's Principles of Internal Medicine, 17e
Calculate Jody’s BMI (height 64 in.,
weight 119 lbs). She is
1.
2.
3.
4.
5.
Underweight
Normal weight
Overweight
Obese
Not enough
information
20%
1
20%
20%
2
3
20%
4
20%
5
BMI Calculation
BMI = (weight in pounds) x 703
(height in inches)2
Jody’s BMI = (119) x 703 = 20.4
(64) 2
Weight Status Category
Underweight
Healthy weight
Overweight
Percentile Range
< 5th percentile
5th - < 85th percentile
85th - < 95th percentile
Obese
≥ 95th percentile
BMI Interpretation
Objective: Physical Exam
• A somewhat muscular, slender
female, who is cooperative and
appears in no acute distress.
Objective: Physical Exam
Head:
Eyes:
Ears:
Normocephalic; face is symmetrical
without maxillary or frontal sinus
tenderness
Clear conjunctiva and sclera, 20/20
for near and far vision without
glasses
External auditory canals patent and
clear; pearly tympanic membrane
without erythema or bulging
Objective: Tympanic Membrane
Objective: Physical Exam
Nose: Clear without discharge
Throat: Marked pharyngeal inflammation;
enlarged tonsils with white
exudates, small petechiae on palate
Neck: Enlarged and tender anterior and
posterior cervical lymph nodes; no
restriction to active or passive range
of motion
Objective: Oropharynx
Objective: Physical Exam
Heart:
Rhythm regular without murmurs;
no palpable thrills or unusual
pulsations
Lungs: Clear to auscultation bilaterally; full
rib excursion
Chest: Symmetrical; no tenderness
Objective: Physical Exam
Abdomen: No distention, bowel sounds
present in all 4 quadrants. Spleen
palpated 2 cm below costal margin,
slightly tender. No hepatomegaly
noted.
Objective: Splenomegaly
• Palpation of anything
more than the tip below
the costal margin
• Percussed as a dull sound
in the lung or abdominal
region
• Usually measure on deep
inspiration
http://www.4to40.com/images/ayurveda/Splenomegaly/
Splenomegaly.jpg
Objective: Physical Exam
Breasts:
Genital:
Rectal:
No masses, nipple discharge, or
tenderness noted
Female; Tanner sexual stage IV
Deferred
Objective: Female Tanner Stage
From Nelson’s Textbook of Pediatrics 2007
http://commons.wikimedia.org/wiki/File:Tanner_scalefemale.svg
Objective: Male Tanner Stage
From Nelson’s Textbook of Pediatrics 2007
From:
http://commons.wikimedia.org/wiki/File:Tanner_
scale-male.svg
Objective: Physical Exam
Back:
Cervical, thoracic and lumbar
curvatures are normal; no scoliosis
noted; range of motion is
unrestricted in cervical, thoracic
and lumbar areas
Extremities: No cyanosis, clubbing, edema or
varicosities; no restriction to active
or passive range of motion
Skin:
No rashes or lesions present
Objective: Physical Exam
Neurological: Cranial nerves II-XII grossly
intact bilaterally; biceps,
triceps, patellar and Achilles
deep tendon reflexes +2
bilaterally
Psychiatric: Affect and fund of knowledge
appropriate; memory, insight
and judgment intact
Assessment: Problem List
• What sort of things do you want to
include on your problem list at this
time?
Assessment: Problem list
•
•
•
•
•
Pharyngitis
Enlarged spleen
Fever
Fatigue
Health maintenance
– Risky behaviors
• Substance abuse
• Sexual intercourse
– Immunizations
• Parent/child communication issues
Assessment: Differential Diagnoses
• Pharygitis
– Bacterial
• Streptococcal
• Gonococcal
– Infectious mononucleosis
• Epstein-Barr Virus
• Cytomegalovirus
• T. gondii
• HIV
• Hepatitis
• Rubella
• Adenovirus
• Peritonsillar abscess
Select your top differential:
1. Gonococcal
pharyngitis
2. Infectious
mononucleosis
3. Peritonsillar
abscess
4. Streptococcal
pharyngitis
25%
1
25%
25%
2
3
25%
4
Infectious mononucleosis
• Called the ‘kissing disease’
• Most often caused by the Epstein Barr
virus
• Virus infections pharyngeal cells and after
release of virons it spreads to other parts
of the body
• Once you mount an immune response
you are protected for life
• Monospot and EBV specific antibody
tests confirm diagnosis
Signs and Symptoms of
Mononucleosis
From-http://www.answers.com/topic/infectious-mononucleosis
Assessment: Diagnoses
• Pharyngitis: Infectious
mononucleosis
• Childhood risky behaviors including
sexual intercourse and substance
use
• Deficient in recommended
vaccinations
Plan: Lab Tests
• Initial decrease in white blood cell
count followed by an increase in the
proportion of lymphocytes
– Many of which are atypical
• Monospot: heterophile antibodies
agglutinate horse RBCs
– Usually become positive within 4
weeks after onset of illness
– Specific but often not sensitive in early
illness
Plan: Treatment
• Supportive management
– Rest
– Fluid hydration
– Pain relief
– Monitor for airway compromise
• Restriction from contact sports until
splenomegaly has resolved
Plan: Treatment
• Vaccines recommended for
adolescents:
– Pertussis (whooping cough)
– Meningococcal infections
– Hepatitis B
– Varicella (chicken pox)
– Measles, mumps and rubella
*Other vaccines may be indicated based on individual
patient needs
Plan: Treatment
• Discuss risky behaviors and possible
consequences
– Sexual activity in adolescents
• Pregnancy
• STIs/STDs
• Emotional development
– Harmful effects of alcohol and drug use
• Cultural and behavioral factors have
the greatest influence on mortality
Minor Patient Confidentiality
• Jody asks to use the restroom
before they leave, and while she is
out of the room her mother
approaches you:
“I think my daughter is having sex with
her boyfriend, and as her mother I
feel I have a right to know. Did she
say anything to you?”
How do you answer Jody’s mother?
1. “She is, but she is using
protection.”
2. “No, she said she hasn’t.”
3. “I don’t know, I’m a
medical student.”
4. “I’m sorry, but I can’t
discuss that issue with
you at this time.”
5. “Probably, but you should
ask her to be sure.”
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20%
20%
2
3
20%
4
20%
5
Minor Patient Confidentiality
• Teens have certain legal protections, so you may
treat them for certain things without their parents
knowledge
• Administration of birth control
• Treatment for STI’s
• Counseling on drugs and ethanol
• Anything if child is emancipated
• Health professionals should always advise teens
to have close communication with parents or
guardians
Learning Objectives:
Review history and physical (H&P)
format
Subjective
Objective
Assessment
Plan
Health maintenance for adolescents
Minor patient confidentiality