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Case #92: Say Ahhhh!BY AMI ALANIZ
Gross OverviewNote the:
Soft palate: general appearence
Tonsil: size and general appearance
The Patient
Profile female 11 years old Caucasion
Past Medical HistoryEar 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 beta-hemolytic 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 Knowo edemao swellingo general response to injury or inflammationo erythema o rednesso results from capillary congestion o exudateo 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 ResultsHB 13.2 g/dL Neutrophils 72% Basophils 1%
Hct 43.9% Lymphocytes 21% ESR 18 mm/hr
Plt 390,000/mm^3 Monocytes 5% CRP 2.3 mg/dL
WBC 15,500/mm^3 Eosinophils 1% (+) Rapid streptococcal antigen test
Case Question #1: Answered
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