A patient presents to your clinic with Fever and sore throat
· Consider what physical exams and diagnostic tests would be most appropriate to gather more information about the patient’s condition.
· Reflect on how the results would be used to make a diagnosis.
· Identify three to five (3–5) possible conditions that may be considered in a differential diagnosis for the patient.
· Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
· Write the History of Present Illness using Subjective findings only
· Plan: Use the expert diagnosis provided to create a pertinent, comprehensive, evidenced-based management plan. Address the following criteria in the plan: 1.) Diagnostic tests; 2.) Medications (write out a complete order, even for OTC meds); 3.) Suggested consults/referrals; 4.) Patient education; 5.) Follow-up, including time interval and specific symptoms to prompt a return visit sooner; 6.) Provide rationales for each intervention and include references to support your plan. Clinical practice guidelines should be utilized as applicable
### History of Present Illness (HPI)
**Subjective Findings:**
The patient is a 25-year-old male who presents to the clinic with complaints of fever and sore throat for the past 3 days. The patient reports a sudden onset of fever, with temperatures peaking at 101.5°F. He describes the sore throat as constant and worsening, particularly when swallowing. The patient also reports mild fatigue, headache, and swollen lymph nodes in the neck. He denies any cough, runny nose, or other respiratory symptoms. The patient has not taken any medications for his symptoms and denies any recent travel, exposure to sick contacts, or known allergies.
### Differential Diagnosis
**Streptococcal Pharyngitis (Strep Throat)**
– Often presents with fever, sore throat, swollen lymph nodes, and absence of cough.
**Viral Pharyngitis**
– Common cause of sore throat, often accompanied by fever, headache, and fatigue; typically self-limiting.
**Infectious Mononucleosis**
– Characterized by fever, sore throat, swollen lymph nodes, and fatigue; often caused by Epstein-Barr virus.
**Tonsillitis**
– Inflammation of the tonsils causing sore throat, fever, and swollen lymph nodes.
**COVID-19**
– Can present with fever and sore throat among other symptoms like fatigue and headache.
### Physical Exams and Diagnostic Tests
**Physical Exams:**
**Vital Signs:** Measure temperature, heart rate, blood pressure, and respiratory rate.
**Throat Examination:** Look for erythema, exudate, or swelling of the tonsils and pharynx.
**Palpation of Lymph Nodes:** Check for tenderness and swelling in the cervical lymph nodes.
**Abdominal Examination:** Assess for hepatosplenomegaly (enlarged liver or spleen), which could suggest infectious mononucleosis.
**Diagnostic Tests:**
**Rapid Antigen Detection Test (RADT) for Group A Streptococcus**
**Throat Culture:** If RADT is negative but suspicion for strep throat remains high.
**Monospot Test (Heterophile Antibody Test):** To check for infectious mononucleosis.
**Complete Blood Count (CBC):** To look for signs of infection or atypical lymphocytes.
**COVID-19 PCR or Rapid Antigen Test**
### Plan
**1. Diagnostic Tests:**
– **Rapid Antigen Detection Test (RADT) for Group A Streptococcus**
– **Throat Culture** (if RADT is negative)
– **Monospot Test**
– **COVID-19 PCR Test**
– **CBC with Differential**
**Rationale:** These tests will help confirm the diagnosis, differentiating between bacterial and viral causes, including ruling out COVID-19.
**2. Medications:**
– **Acetaminophen 500 mg PO every 6 hours as needed for fever and pain**
– **Amoxicillin 500 mg PO every 12 hours for 10 days** (if RADT is positive for Group A Streptococcus)
– **Ibuprofen 400 mg PO every 6-8 hours as needed for pain**
**Rationale:** Acetaminophen and ibuprofen will help manage fever and pain. Antibiotics are indicated if bacterial infection (strep throat) is confirmed.
**3. Suggested Consults/Referrals:**
– **Otolaryngologist (ENT specialist):** If there is no improvement with initial treatment or if complications arise.
– **Infectious Disease Specialist:** If infectious mononucleosis is confirmed and there are concerns about complications or prolonged symptoms.
**Rationale:** Specialist consultations may be necessary for persistent symptoms, complications, or complex cases.
**4. Patient Education:**
– **Discuss the importance of completing the full course of antibiotics** if prescribed.
– **Encourage rest and hydration.**
– **Advise on symptom management with OTC medications (acetaminophen, ibuprofen).**
– **Educate about hand hygiene and avoiding close contact with others to prevent the spread of infection.**
– **Discuss potential symptoms of complications and the importance of follow-up.**
**Rationale:** Education helps ensure compliance with treatment and reduces the risk of complications and transmission.
**5. Follow-Up:**
– **Re-evaluate in 3-5 days if symptoms do not improve.**
– **Immediate follow-up** if symptoms worsen or new symptoms such as difficulty breathing, severe pain, or rash develop.
**Rationale:** Timely follow-up ensures monitoring of the patient’s response to treatment and early detection of any complications.
### References
– American Academy of Pediatrics. (2018). Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis. Pediatrics.
– Centor, R. M., & McIsaac, W. (2004). Streptococcal Pharyngitis: Clinical Review. JAMA.
– Institute for Clinical Systems Improvement (ICSI). (2020). Diagnosis and Treatment of Respiratory Illness in Children and Adults.
– Mayo Clinic Staff. (2021). Infectious Mononucleosis (Mono). Mayo Clinic.
– World Health Organization. (2021). Coronavirus disease (COVID-19) advice for the public.
The post A patient presents to your clinic with Fever and sore throat appeared first on Destiny Papers.
