Case Studies

Case Studies

#1 Anxiety (differential diagnosis 1) Cardiac disease 2) Substance abuse 3) hyperthyroidism)

#2 Trichomoniasis (differential diagnosis 1) gonorrhea 2) chlamydia 3) vaginal cancer)

please provide 3 differential diagnosis as you will see what I’m referring to when you open my supporting files.

Please be familiar with nursing, medical terms, and carefully review the examples before responding. You may use the template case study to complete the assignment.

CASE STUDY: ACUTE EXUDATIVE TONSILLITIS

PATIENT INFORMATION: S.J. is a 17-year old Caucasian male. CHIEF COMPLAINT: Sore throat for 2 days

HISTORY OF PRESENT ILLNESS: S.J. was brought in by his mother because of sore throat which occurred two days prior to consult. Mother shared that her son was exposed to a classmate with similar symptoms one day prior to the appearance of his symptoms. S.J. describes his sore throat as constant, burning in nature, 9/10 on the pain scale and worsens with eating and swallowing especially non liquid food. This was also associated with hoarseness, headache, body weakness and high fever (maximum reading of 101.9 F) which breaks off with intake of Tylenol 500 mg every 4 hours as needed. Patient also states that he would experience some relief of sore throat when drinking warm lemon juice. Due to his symptoms progressively getting worse, mother decided to bring him for medical consultation.

ALLERGIES: No known food or drug allergies.

PAST MEDICAL HISTORY: Patient denies any previous hospitalizations and presence of other co morbid medical conditions. Immunization status up to date.

PAST SURGICAL HISTORY: Patients denies any previous surgeries. FAMILY HISTORY: (-) Heart Disease, Kidney pathology, Rheumatic Fever

SOCIAL HISTORY: High school student attending public education, resides with parents and 2 other younger siblings. Denies smoking, alcohol intake, and tobacco or illicit drug use.

SEXUAL HISTORY: Sexually active, in a monogamous relationship with current partner.

REVIEW OF SYSTEMS:

Constitutional: No chills, weight changes, fatigue, weakness, night sweats.

Skin: No rash, discoloration, itching, pruritus, lumps/bumps, nail, or hair changes. Head: (+) headache, no dizziness, lightheadedness, or vertigo.

Eyes: No changes in vision, eye pain, tearing, eye discharge.

Ears: (+) ear pain bilaterally worse with swallowing, no aural discharge, ear fullness, tinnitus, or hearing loss.

Nose/Sinuses: No congestion, nasal discharge, epistaxis, sinus pain, sneezing, Oral: No sores, dental cavities, gum lesions or gingivitis, gum bleeding.

Throat/Neck: (+) sore throat, hoarseness, dysphagia, no neck pain, no neck swelling. Cardiovascular: No chest discomfort, palpitations, orthopnea, shortness of breath.

Respiratory: No dyspnea, cough, hemoptysis, shortness of breath, wheeze. Gastrointestinal: Unable to eat well due to painful swallowing, no abdominal pain,

heartburn, nausea, vomiting, changes in bowel habits or blood in stools.

Genitourinary: No dysuria, hematuria, urinary frequency, incontinence, genital discharge.

Musculoskeletal: No leg pain, cramps, joint pain, joint stiffness, swelling, weakness. Neurological: No headaches, seizures, tremors, numbness, tingling.

Endocrine: No polyphagia, polydipsia, polyuria, denies intolerance to heat or cold. Hematological: No easy bruising, anemia.

Psychiatric: No anxiety, feeling of sadness, mood swings, insomnia.

PHYSICAL EXAMINATION:

General Survey: Patient is awake, alert, oriented, not in acute respiratory distress. VS: BP:110/78 mmHg PR: 100/min RR: 18/min Temp:101F (oral) O2 sat: 98% Hgt: 5’7” Wgt:150 lbs BMI: 23.49

Skin: pink, warm, moist, intact, no rashes, no atypical pigmentation.

Head: normocephalic, even hair distribution, no scalp lesions or bald spots, no scalp tenderness or palpable mass.

Eyes: no ptosis, pink palpebral conjunctivae, anicteric sclerae, pupils equally reactive to light and accommodation, (+) red orange reflex bilaterally, fundoscopic findings shows no papilledema, no retinal hemorrhages, blood vessels appear normal with sharply demarcated optic disc.

Ears: normal pinna, no lesions, no tragal tenderness, otoscopy showed non erythematous ear canal, minimal cerumen, no aural discharge, tympanic membrane pearly gray, good cone of light, no bulging or retraction, bilaterally.

Nose/Sinus: nasal septum midline, nostrils patent bilaterally, no nasal discharge, pink nasal mucosa, no bogginess noted, no tenderness over frontal and maxillary sinuses.

Oral/Throat: pink moist oral mucosa, no oral lesion, good dentition, no dental caries, no halitosis, no gum lesions, swelling or bleeding. Pink pharyngeal wall, cherry red swollen tonsils (+3) with yellowish exudates bilaterally.

Neck: supple, no tenderness, no stiffness, carotid pulse with normal upstroke, no bruit appreciated. Palpable mobile, enlarged tender superficial cervical lymph nodes bilaterally, trachea midline, thyroid normal size and consistency, no palpable mass.

Cardiac: normal rate regular rhythm, no heaves, no thrills, S1 and S2 sounds normal, PMI best appreciated on the 5th ICS-MCL, no murmur.

Lungs: respiratory effort even and unlabored, no intercostal or supraclavicular retractions, symmetrical chest expansion, equal tactile fremitus bilaterally, resonant on percussion, clear breath sounds on all lung fields, no wheeze, no ronchi, no rales.

Abdomen: flat, no skin discoloration, no visible lesion, flat umbilicus, normoactive bowel sounds, soft, no tenderness on palpation, liver span 7 cm, spleen non palpable, no mass

Genitalia: Tanner stage V, normal looking circumcised penis, no penile discharge, testes bilaterally descended, non tender, no swelling, no palpable scrotal or testicular mass.

Extremities: no rashes, no abnormal pigmentation, no edema, no swelling, no deformity, pulse full and equal on all extremities, good range of motion, muscle strength 5/5 on all extremities. DTRs (+2) bilaterally.

Neurologic: alert, oriented to time, and place, responds appropriately to questions, CN I – XII intact, good coordination and balance, no gross or fine motor deficits.

ASSESSMENT:

PRIMARY DIAGNOSIS: Acute Exudative Tonsillitis

The patient is this case study presented with an acute onset of sore throat, fever, odynophagia (painful swallowing), hoarseness, and otalgia (ear pain) coupled with the physical findings of erythematous and edematous enlargement of the tonsils bilaterally and presence of anterior cervical lymphadenitis which strongly suggest a diagnosis of Acute Tonsillitis. The presence of yellowish exudates is highly suggestive of bacteria as the etiologic agent of the disease thus descriptive of an exudative type of tonsillitis. The patient’s

course of illness patterns that of the classic presentation of Acute Tonsillitis. This is further strengthened by a positive history of exposure to an individual who presented with the same symptoms.

PATHOPHYSIOLOGY:

Tonsillitis is defined as inflammation of the tonsils. Tonsils are part of the lymphoid system of the body and has a significant role in fighting infections. They appear as pink fleshy structures on each side of the pharynx and are equal in size. Tonsils typically have pits called crypts running through its mucosa which are colonized by different types of microorganisms. Microscopically, tonsils also have lymph nodules which are made up of immune cells particularly B cells, T cells, and macrophages. Tonsils are part of the Waldeyer’s ring which consists of the palatine, lingual, and tubal tonsils together with the adenoids. Until the age of 6, tonsils are expected to be hyperplastic after that they start to regress in size and shrink by 12 years of age. When a patient has tonsillitis, the palatine tonsils are mainly involved. Palatine tonsils are highly vascularized which is why bleeding is one of the most common post operative complication following tonsillectomy.

Tonsillar invasion by either viral or bacteria result to infection. Insults caused by microorganism leads inflammatory responses. The mode of transmission is droplet infection by either close or direct contact (coughing, sneezing, kissing, touching contaminated object). Common viruses causing tonsillitis include Ebstein Barr virus, Adenovirus, Rhinovirus, Coronavirus, Influenza and Parainfluenza viruses while the main bacterial etiologic agent involved is Group A Beta-hemolytic Streptococcus (GABHS), however Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenza have also been identified as

possible causes. Viral etiology is more common than bacterial. It is therefore crucial for the health care provider to identify the difference in order to provide appropriate medical management. The signs and symptoms of Acute Exudative Tonsillitis such as sorethroat, fever, pain, tonsillar erythema and edema, lymphadenitis are due to the release of inflammatory cytokines by the pathogen invasion. Inflammatory cytokines cause increased vascular permeability and leakage of protein and fluid into the surrounding tissues resulting to tonsillar edema. In addition, cellular injury and hemolysis causing erythema, release of pyrogens resulting to fever, and increase in lymph drainage into regional lymph nodes leading to cervical lymphadenitis, simultaneously occur. The findings of yellowish exudates can be explained by the cytokine mediated leucocyte activation, infiltration, and opsonization of the pathogen at the tonsillar site resulting to accumulation of cellular debris and byproducts of the inflammatory response (Marchak, 2008). The presence of otalgia (ear pain) in a patient with Acute Tonsillitis but with no evidence of ear infection is often considered a referred pain due to the involvement of the Jacobson’s nerve, a derivative of the glossopharyngeal nerve (CN IX). Cranial nerve IX provides sensory innervation to the oropharynx, middle ear, eustachian tube, posterior third of the tongue, the carotid body and sinus. According to a study conducted by Z. Abd-Alkader Taboo and M. Buraa on the etiology of otalgia, referred otalgia may be experienced when there is presence of inflammatory lesions of the palatine tonsils, nasopharynx, soft palate or the posterior third of the tongue due to the involvement of the sensory arm of the glossopharyngeal nerve (Taboo and Buraa, 2013). In the initial stage of tonsillitis, it is extremely difficult to distinguish viral from bacterial cause. As a health care provider, it is crucial to correctly identify the cause of

Acute Tonsillitis to prevent potential life threatening complications which include Rheumatic Fever, Scarlet Fever, and Post Streptococcal glomerulonephritis, and peritonsillar abscess to name a few. For this reason, it highly recommended that clinicians utilize the Modified Centor Scoring system which is a set of criteria that provides an estimate risk of GABHS in a patient presenting with tonsillopharyngitis. The criteria include absence of cough, presence of anterior cervical lymph nodes, temperature of 100.4 F or 38 C, presence of tonsillar exudates or swelling, and age groups divided into 3-14 years old, 15 – 44 years old, and 45 years old and older. A score of 1 is assigned for each criterion except for the older age group. Age group 15 – 44 is assigned 0 while the oldest age group receive a -1 score. Risk scores and corresponding management are as shown (Choby, 2009).

Clinical Decision Rule for Management of Sore Throat

 

DIFFERENTIAL DIAGNOSES:

1. Infectious Mononucleosis

This disease was considered because patient in this case study belongs to the age group (15 – 30 years old) where infectious mononucleosis is most common as well being sexually active with his partner. This disease is also known as kissing disease because it is spread through infected saliva. It is caused by Ebstein Barr virus which belongs to the Herpes viruses. Patients with infectious mononucleosis also present with sorethroat, fever, generalized lymphadenitis, and tonsillar enlargement and injection. The distinctive features of patient with infectious mononucleosis is its insidious onset, the character of the exudates which appear as white and gray deposits, and presence of hepatosplenomegaly in some cases. This disease entity was ruled out in this case study on the basis of the acute onset of sorethroat, the character of the exudates which is yellowish rather than white or gray, and the absence of hepatosplenomegaly.

2. Peritonsillar Abscess

Peritonsillar abscess is a complication of a tonsillar infection. Symptoms are not usually apparent until about 5 days from the time abscess formation starts. Peritonsillar abscess also presents with sore throat, painful swallowing, fever, chills, and ear pain usually on the same side of the abscess. However, the characteristic features that distinguish this diagnosis from a simple Acute Tonsillitis are the presence of trismus (spasm of the jaw muscles), torticollis (spasm of the neck muscles) as well as a muffled voice described as “hot potato” voice (talking as if you have a mouthful of hot potato). Clinical findings include an enlarged and displaced tonsil and uvula as well as swelling of the peritonsillar area. There

could also be unilateral neck swelling. Absence of these symptoms and physical findings in this patient strongly rules out this diagnosis.

3. Gonococcal Pharyngitis

This is common in the adolescent age group with history of oral-genital sex. Although there is no established history of oral-genital sex in this case study, the patient admits to being sexually active with his partner. The main symptom of gonococcal pharyngitis is sore throat however majority of infected patients have little or no symptoms. Throat findings are similar to that of Streptococcal infection such white yellowish tonsillar exudates.

PLAN:

DIAGNOSTIC TESTS:

1. Confirmatory Microbiological Tests:

A. Rapid Antigen Detection Test – performed by doing a throat swab to determine Group A Beta Hemolytic Streptococcus infection. The test detects the group specific carbohydrate antigen on the GABHS cell wall and identifying the antigen by way immunologic reaction (Leung et.al, 2006). The advantage of this test is that the result is readily available to the provider in about 10 – 15 minutes thus an appropriate treatment can be provided immediately. Other positive aspects of this tests include less incidence of complications, shortens illness days, reduces the chance of spreading infection, decrease in antibiotic abuse and misuse, and lesser down time for patients allowing them to go back to work or school quicker. Much as it is a highly specific test (>95% specificity), there is a also a downside to the test, that is, the possibility of getting false negative results. For this reason, a throat culture is always recommended.

B. Throat Culture – provides the most definitive result in so far as identifying the etiologic agent of Tonsillitis. This test is most helpful especially in patients whose rapid antigen test is negative but is clinically showing signs of bacterial tonsillitis. This test is performed likewise by doing a throat swab. As with any tests, good results depend on good samples. Ask patient if antiseptic mouthwash was used prior to swab as this may alter results. This test can also be used for detection for Neiserria Gonorrhoea, the bacteria that causes Gonococcal pharyngitis. The technique is the same, they just differ in the medium used for culture. The medium used to test for gonorrhea is Thayer Martin whereas the medium used to detect Streptococcal infection is blood agar. The downside of this test is that it takes several days for the result to be ready.

C. Monospot Test – a test for mononucleosis which involve a fingerstick or blood sample collection. The results are readily available within 5 – 10 minutes. The test is based on blood agglutination. A positive monospot test means presence of heterophile antibodies. The disadvantage of this test is its high rate of false negative results in patients who are younger than 4 years old and if the test was conducted early in the course of illness. Studies show that if monospot test is obtained 1 – 2 weeks from the onset of symptoms, the rate of false negative results are higher. This is due to the fact that heterophile antibodies has not yet reached its threshold (Stuempfig & Seroy, 2019).

2. Ancillary Laboratory Tests

A. Complete Blood Count – there is an increase of white blood cells particularly neutrophils which supports bacterial infection. In viral infection, typically the CBC picture will be that of lymphocytic predominance, although this is not always the case. In severe

infection such as peritonsillar abscess, there will be overwhelming neutrophilia.

B. Erythrocyte Sedimentation Rate – blood sample is taken to determine how quickly red blood cells settle at the bottom of the test tube when the test is run. A normal result will show slow settling of RBC. A faster than normal rate indicates inflammation.

C. C-Reactive Protein – a protein is produced by the liver. CRP is detected in the blood levels when there is inflammation occurring in the body . Note that CRP levels are elevated in acute or chronic inflammation.

3. Diagnostic Imaging – typically this is not as part of the initial approach for a patient presenting with Acute Tonsillitis or Peritonsillar abscess since both are clinical diagnoses. However if there is a strong suspicion that the infection has spread in the deep neck structures then it is imperative to order Xray or CT scan of the lateral neck be as this might

compromise airway and also lead to systemic infection.

MEDICAL MANAGEMENT:

Medical management of Acute Tonsillitis is generally done on an outpatient basis. On rare occurrence, hospital admission may be necessary in severe cases. After conducting a Centor score screening and obtaining a Rapid Antigen Detection Test, patients with Centor score of 3 or 4 and a positive RADT will receive empirical treatment of antibiotics.

Traditionally the first line of antibiotic is broad spectrum Penicillin. However, oral Amoxicillin is often substituted for its better taste. Beta lactam antibiotics are effective not only in eradicating the streptococcal infection but also providing relative protection from complications such as rheumatic fever. According to American Academy of Family Physician, antibiotic treatment for a patient with acute bacterial tonsillitis is as follows:

Penicillin V – children: 250 mg two to three times per day, adolescents and adults: 250 mg three to four times per day or 500 mg two times per day. Amoxicillin – children (mild to moderate GABHS pharyngitis) 12.25 mg per kg two times per day or 10 mg per kg three times per day, children (severe GABHS pharyngitis) 22.5 mg per kg two times per day or

13.3 mg per kg three times per day, adults (mild to moderate GABHS pharyngitis) 250 mg three times per day Or 500 mg two times per day, adults (severe GABHS pharyngitis) 875 mg two times per day (Choby MD, 2009). The length of antibiotic treatment is 10 days.

Macrolides (Clarithrymocin, Erythromycin, Azithromycin) are effective alternative antibiotic for patients allergic to Penicillin/Amoxicilin. The advantage of prescribing macrolides is that it is taken for a shorter period of time, typically 3 – 5 days as compared to 10 days with Penicillin or Amoxicillin treatment. This results to better patient compliance and completion of the full course of antibiotic treatment.

Part of the complete management is providing supportive measures such as oral hydration, analgesics, and/or steroids for pain relief. Avoid the use of Aspirin in patients younger than 20 years of age as it is linked to a serious disease called Reye Syndrome. Traditional warm salt water gargle (1 tsp of salt in 8 oz of warm water) and plenty of rest is advised. Use of humidifier or vaporizer may also provide soothing relief.

Tonsillectomy is not yet recommended at this time. This procedure is reserved for chronic and recurrent tonsillitis, extremely hypertrophic tonsils described as kissing tonsils, history of peritonsillar absence, and history of poor response to antibiotic treatment. Meeting the Paradise criteria is an another indication for tonsillectomy in the pediatric population. The criteria looks at the frequency of sore throat episodes (> 7 in the past year or > 5 in the past 2

years or > 3 in the past 3 years), clinical features which includes fever (T > 100.9 F), cervical lymphadenopathy (>2 cm), tonsillar exudate, positive GAHBS culture, antibiotic treatment for each episode of infections, and clinical documentation of each episode of infection is in patient’s clinical records (Stelter 2014).

PROGNOSIS:

Acute Tonsillitis is a self-limiting disease and resolves without sequelae with adherence to the full course of antibiotic treatment. Patient may return to usual activity after 24 hours of antibiotic therapy.

FOLLOW UP CARE/REFERRAL:

Follow up care with primary health care provider after 72 hours is recommended if sore throat does not improve or became progressively worse and if fever does not break off. A referral to ENT specialist may be necessary. During routine follow up, check for heart murmur and joint pains which suggest complication related to Rheumatic Fever.

PATIENT EDUCATION:

Explain to the patient the importance of completing the full course of antibiotic to prevent complications. Instruct patient to seek immediate medical consult if experiencing difficulty breathing, if painful swallowing becomes progressively worse, and if there is occurrence of one -sided neck or throat swelling. In the same manner, patient should be instructed to contact the provider if sore throat persist for more than 3 days or if fever does not break after treatment.

Educating the patient on practical preventive measures such as frequent proper hand washing and cough etiquette is essential to the complete care of tonsillitis. Because the patient is a young adult, providing education on safe sex practice is also helpful.

REFERRENCES

Marchak,A. (2018). Tonsillitis: pathogenesis and clinical findings. The Calgary Guide to Understanding Disease, https://calgaryguide.ucalgary.ca

Abd-Alkader Taboo, Z., Buraa, M. (2013). Etiology of referred otalgia. The Iraqi Postgraduate Medical Journal, 12(3), 436-442.

Choby MD, B. (2009). Diagnosis and treatment streptococcal pharyngitis. American Family Physician, 79(5), 383-390. https://www.aafp.org/afp/2009/0301/p383.html.

Stetler, K. (2014). Tonsillitis and sore throat in children. German Medical Science Current Top Otorhinolaryngol Head Neck Surgery, 13(7), doi: 10.3205/cto000110.

Stuempfig N., Seroy J.(2019). Monospot test. StatPearls [Internet], StatPearls Publishing,

https://www.ncbi.nlm.nih.gov/books/NBK539739.

Vincent MD, et al. (2004). Pharyngitis. American Family Physician, 15, 69(6), 1465-1470, https://www.aafp.org/afp/2004/0315/p1465.html

Leung, et al.(2006). Rapid antigen detection testing in diagnosing group A beta-hemolytic streptococcal pharyngitis. Expert Review of Molecular Diagnostics. 6(5), 761-6, https://www.ncbi.nlm.nih.gov/pubmed/17009909.

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