Case study #1

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 A 72-year-old woman presents to her regular primary care physician (PCP) with a 2-day history of fatigue, malaise 


Case Study #1

A 72-year-old woman presents to her regular primary care physician (PCP) with a 2-day history of fatigue, malaise, and fever. She awoke this morning with a dull ache in her right mid-back and some nausea. She came to the office because she is concerned about the pain and her worsening symptoms. She has been resting and taking acetaminophen (650 mg every 4 to 6 hours), which has helped with the fever and aches, but her symptoms return as the drug wears off. She is unsure of how high her fever has gotten. She states the pain is a 3 or 4 /10, however the fatigue, malaise, and nausea have kept her from her daily activities and caused her to remain in bed most of yesterday and all day today. She suspects she might have caught “the flu” though she received the vaccine 3 weeks ago. She is most concerned because she lives alone and is nervous of becoming seriously ill and having no way to call for help. She denies ever smoking and drinks a glass of wine only once or twice a month.
Her husband of 50 years died 8 years ago of prostate cancer, and she lives independently in an apartment. One of her three children lives a few miles away and visits frequently. She is not currently sexually active.

She denies chills, night sweats, rhinorrhea, cough, shortness of breath, dyspnea, chest pains, palpitations, vomiting, diarrhea, or constipation. She admits to increased urinary frequency and urgency but denies pain with urination. She denies sick contacts or changes to her dietary routine.

Review of Symptoms and Relevant History

Positive for occasional knee pain. Her review of systems is negative for weakness, weight loss, focal pain except in the right flank, difficulty with memory or concentration, recent illness, or injury.

The patient’s history is significant for hypertension and osteoporosis. She has a family history of coronary artery disease (CAD). Her daughter lives nearby and is available to stay with her if needed.

Allergies: No medication, environmental, or food allergies

Current Meds: Lisinopril/hydrochlorothiazide 10/12.5 mg daily for hypertension, Alendronate 70 mg weekly for osteoporosis, Over-the-counter (OTC) calcium citrate 1,000 mg with 600 IU vitamin D3 daily for osteoporosis


Physical Exam Findings:


Vitals:
 T 38.8°C (101.8°F), P 96, R 14, BP 106/68, WT 56.7 kg (125 lbs), HT 172.72 cm (68 in.), BMI 20.2.


General:
 Ill and uncomfortable appearing, but non-toxic and without acute distress.


Psychiatric:
 Alert and oriented to person, place, and time; coherent conversation.


Skin, Nails:
 Skin pale and slightly flushed, no rash or lesion. Nails are smooth without hemorrhage.


HEENT:
 Eyes without retinal lesions; oral mucosa moist without lesions.


Chest:
 Symmetric excursion with no accessory muscle use.


Lungs:
 Resonant with vesicular breath sounds all fields; no wheezes, rales, or rhonchi.


Breasts:
 No mass or lesion bilaterally.


Heart:
 Quiet precordium; RSR; no murmur, rub, or gallop.


Abdomen:
 Flat, normoactive bowel sounds all quadrants, no mass. There is mild right costovertebral angle (CVA) tenderness and mild suprapubic discomfort but no tenderness.


Genital/Rectal:
 Vaginal and introital mucosa show atrophy. The uterus is small and smooth. No mass or lesion detected in the adnexa or cul-de-sac.


Musculoskeletal:
 No point tenderness detected on the vertebral processes.

Discussion:

1. Differential Diagnosis: Please list at least (and reference the background and pathophysiology with at least 2 sources)
three differential diagnoses with the first diagnosis being your primary (most likely) diagnosis to demonstrate your understanding.

2. What if any diagnostic tests/imaging studies be ordered and Why? Consider testing in the Primary and Acute care setting as well.

3. Following these diagnostic tests as per above, what is the next step, explain based on your differentials what you plan to do next and why.

4. Review a recent and credible research article about the key factors (causes, risks, diagnostic testing, and treatment selection) of this primary diagnosis. Provide references for your response in APA format.

5. Patient education – Please document what is pertinent for education and why. For example, If smoking cessation is your plan for education, list why and how you will assist the patient with smoking cessation (i.e, referral or enrollment in group therapy, nicotine therapy, patches, Nicorette etc). Explain your education plan.

6. If not managed appropriately, what are the medical/legal concern(s) that may result from mismanagement?

7. List any collaborative opportunities. Provide a list of any specialties or other disciplines and indicate what contribution these professionals might make to managing the patient.


APA FORMAT, AND REFERENCES, scholarly resource cited in APA format from 2018-2023 only. (Within the last 5 years)

Please do not solely use a website as your scholarly reference, fine to use as supplement, but a journal article should be referenced or a text.

Please use reliable medical references such as your Goroll text, your Current Medical Diagnosis and Treatment book, or UpToDate. 
Do NOT use WebMD, Wikipedia etc. as these are not advance practice references.  

APA format (if using outside sources).


-General
 Usual weight, recent weight change, weakness, fatigue, or fever


-Skin  
 Rashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails, changes in size or color moles 


-Head, Eyes, Ears, Nose, Throat (HEENT):
 






Head: Headache, head injury, dizziness, lightheadedness.
Eyes: Vision, glasses or contact lenses, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts.
Ears: Hearing, Tinnitus, Vertigo, earaches, infection, discharge, If hearing is decreased, use or nonuse of hearing aids,
Nose and Sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nose- bleeds, sinus trouble.
Throat (
or mouth and Pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, sore tongue, dry mouth, frequent sore throats, hoarseness.





-Neck
 “Swollen Glands,” goiter, lumps, pain, or stiffness in the neck. 





-Breast
 Lumps, pain, or discomfort, nipple discharge






-Respiratory
 Cough, sputum (color quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (Pleuritic pain).




-Cardiovascular
 “Heart trouble”; high blood pressure; rheumatic fever; heath murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea) swelling in the hands , ankles, or feet (edema). 





-Gastrointestinal
 Trouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and size, change bowel habits, pain constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble. 





-Peripheral Vascular
 Intermittent leg pain with exertion (Claudication); leg cramps; varicose veins; past clots in the veins; past clots in the veins; selling in claves, legs, or feet; color change in fingertips or toes during cold weather; selling with redness or tenderness.





-Urinary
 Frequency or urination,  polyuria, nighttime urination (nocturia), urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence;  in males, reduced caliber or force of the urinary stream, hesitancy, dribbling. 


-Genital
 



Male: Hernia, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infection and their treatments. Sexual interest (Libido), function, satisfaction

Female: Menstrual regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension. Menopausal symptoms, post-menopausal bleeding. Vaginal discharge, itching, sores, lumps, sexually transmitted infection, and treatments. Sexual interest, satisfaction, any problems, including pain during intercourse (dyspareunia)




-Musculoskeletal
 Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain , tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness. 





-Psychiatric
  Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts. 





-Neurologic
 Changes in mood, attention, or speech;  changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness, loss of sensation, tingling or “pins and needles,” tremors or other involuntary movement seizures. 





-Hematologic
 Anemia, easy bruising, or bleeding





-Endocrine
 Heat or cold intolerance, excessive sweating ,excessive thirst (polydipsia), hunger (polyphagia), or urine output (polyuria).


-Physical Examination
 


General Survey:
 MN is a short, overweight middle-aged female, who is animated and responds quickly  to questions. Her hair was well groomed. Her color is good, and she lies flat.


Vital Signs:
 Ht(without shoes) 157 cm (5’2”). Wt (dressed) 65 kg (143 lbs) . BMI 26, BP 164/98 right arm supine; 160/96 left arm, supine; 152/88 right arm, supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6F.


Skin:
  Palms cold and moist, but color good. Scattered Cherry angiomas over upper trunk. Nails without clubbing , cyanosis. 




Head, Eyes, Ears, Nose, Throat (HEENT): Head;
hair of average texture, Scalp without lesions, normocephalic/ atraumatic (NC?AT).

Eyes;
Vision 20/30 in each eye. 



Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm, round, regular, equally reactive to light. Extraocular movements intact. Disc margins sharp, without hemorrhage, exudate. No arteriolar narrowing or A-V nicking.

Ears:
 Cerumen partially obscures right tympanic membrane (™); Left canal clear, ™ with good cone of light. Acuity is a good to whispered voice. Weber midline. AC>BC.

Nose

 Mucosa pink, septum midline. No sinus tenderness.

Mouth: 
Oral mucosa pink. Dentition is good. Tongue midline. Tonsils absent. Pharynx without exudates. 


Neck:
 Neck Supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.


Lymph Nodes:
 No cervical, axillary, or epitrochlear nodes. 


Thorax and Lungs:
  Thorax Symmetric with good excursion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.




Cardiovascular:
 Jugular venous pressure 1 cm above the sternal angle, with the head of the examining table raised to 30 degrees. Carotid upstrokes brisk, without bruits. Apical impulse discrete and tapping, barely palpable in the 5th left interspace, 8 cm lateral to the midsternal line. Good S1,,.S2,: no S3 or S3,. A II/VI medium-pitched midsystolic murmur at the 2nd right interspace; does not radiate to the neck. No diastolic murmurs. 


Breast:
  pendulous, symmetric.. No masses; nipples without discharge. 




Abdomen:
Protuberant. Well-healed scar, right lower quadrant. Bowel sounds active. No tenderness or masses. Liver span 7cm  in right midclavicular line; edge smooth, palpable 1 cm below right costal margin (RCM). Spleen not felt. No costovertebral angles tenderness (CVAT).


Genitalia:

Female External genitalia without lesions. Mild cystocele at introitus on straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge. Uterus anterior, midline, smooth, not enlarged . Adnexa is not palpated due to obesity and poor relaxation. No cervical or Adnexal tenderness. Pap Smear taken. Rectovaginal wall intact. 

Male External genitalia without discharge or lesions. No scrotal or testicular mases or swelling, no hernia.

Rectal: No external hemorrhoids, tight sphincter tone, rectal vault without masses, stool brown negative for occult blood.

Extremities: Bilateral upper extremities warm. Bilateral lower extremities; no edema. Calves supple, symmetric, temperature intact bilaterally with negative Homan’s sign.

Peripheral vascular: No varicosities in lower extremities. No stasis pigmentation or ulcers Pulses. (2+ = normal)



_________________________________________________________        

Radial           Femoral      Popliteal       Dorsalis Pedis    Posterior Tibial

_________________________________________________________

Rt 2+ 2+ 2+ 2+ 2+

_______________________________________________________

Lt 2+ 2+ 2+ 2+ 2+




Musculoskeletal:
  No joint deformities or selling on inspection and palpation. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles. 





Neurologic: Mental Status:
 Alert and cooperative. Thought processes are coherent and insight is good. Oriented to person, place, and time. Cranial

nerves:
II to XII intact.

Motor:
Good muscle bulk and tone.

Strength:
5/5 bilaterally in deltoids, biceps, triceps, hand grips, iliopsoas, hamstrings, quadriceps, tibialis anterior, and gastrocnemius.

Cerebellar:
Rapid Alternating movements (RAMs)  and point-to-point movements intact. Gait stable, fluid.

Sensory:
 Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative.

Reflexes:
Bilateral triceps, brachioradialis, patellar and Achilles deep tendon reflexes intact. Bilateral plantar reflex intact. Babinski response is negative.

1


CHIEF CONCERN

“A sore throat” that keeps getting worse feels like I am swallowing knives.”


HISTORY OF PRESEENT ILLNESS

Julie is a 35-year-old African American female with history of asthma, and HTN that presents with a “sore throat” for the past 3 days. She states that it is not getting any better, only worse. She is concerned because she saw some redness on the back of her throat. She reports “Odynophagia” when tries to swallow, she reports that she has been having a hard time eating and drinking due to the pain. She reports Halitosis throughout the day over the past three days. She reports coughing occasionally. She rated the pain in her throat as 7/10 on the pain scale. She reports that pain did not improve with Tylenol


PAST MEDICAL HISTORY

Childhood illness: diagnosed with asthma at 14 years

Adult illness:

·
Medical: HTN

·
Surgical: cholecystectomy at age 27

·
OB/Gynecological: Gravida 1, A None reported

·
Psychiatric: None

Current medications: Albuterol PRN for asthma, lisinopril 5mg PO once daily for HTN.

Allergies: Shrimp-Anaphylaxis, Latex-Rash.


Health Maintenance:

·
Immunization: Age-appropriate Up-to-date vaccinations according to the immunization registry.

·
Screening test: Skin lesion biopsy at age 30.


PSYCHOSOCIAL

Julie is married and has a 3-year-old son. Nonsmoker, she drinks wine socially; admitting to 2-3 glasses a few nights a week. Julie works as a receptionist at a car dealership. She is an avid outdoor enthusiast. She hikes regularly and tries to travel when she can to tropical locations. Her last trip was a few weeks ago. She traveled by airplane to Puerto Rico.


FAMILY HISTORY

Mother (65-Year-old) alive with HTN, HLD, CVA, Father (68 years old) alive with CAD, HTN, HLD, DM, Husband (39 years old) alive with HTN, Son (3 years old) alive with asthma


REVIEW OF SYSTEMS



General: Denies recent weight changes, weakness, denies fever, chills, rigor, or sick contacts, denies fatigue.

Skin: Denies rashes, lumps, sores, itching, dryness, and color change. Denies changes in hair or nails, changes in size or color moles.

HEENT (Head, Eyes, Ears, Nose, and Throat):

Head: Denies headache, head injury, dizziness, lightheadedness
. Eyes: Denies changes in Vision, glasses or contact lenses, denies pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts.
Ears: Denies changes in hearing, Tinnitus, Vertigo, earaches, infection, discharge.
Nose, and sinuses: Denies frequent colds, nasal stuffiness, discharge, or itching, hay fever, denies nose- bleeds, sinus trouble.
Throat:
(or mouth and Pharynx): denies bleeding gums, sore tongue, dry mouth, hoarseness, endorses sore throats, endorses redness on the back of her throat.

Neck: Denies Swollen Glands, goiter, lumps, pain, or stiffness in the neck.

Breast: Denies Lumps, pain, or discomfort, nipple discharge.

Respiratory: endorses “occasional cough”. Denies sputum, hemoptysis, denies shortness of breath (dyspnea) wheezing, pain with deep breath (pleuritic pain).

Cardiovascular: endorses high blood pressure. denies rheumatic fever or heart murmurs, denies chest pain, denies palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea) swelling in the hands , ankles, or feet (edema).

Gastrointestinal: denies low appetite. endorses difficulty swallowing, denies heartburn, nausea, denies changes in bowel movements, stool color and size, change bowel habits, denies pain with defecation, rectal bleeding, black or tarry stools, hemorrhoids, constipation, diarrhea. Denies abdominal pain, food intolerance, excessive belching or passing of gas. Denies yellowing of the skin sclera (Jaundice), liver, or gallbladder trouble.

Peripheral Vascular: Denies. Intermittent leg pain with exertion (Claudication); leg cramps; varicose veins; past clots in the veins; selling in claves, legs, or feet; color change in fingertips or toes during cold weather; selling with redness or tenderness.



Urinary: Denies Frequency or urination, polyuria, nighttime urination (nocturia), urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence, denies reduced caliber or force of the urinary stream, hesitancy, dribbling.

Genital: Denies abnormal menstrual irregularity, monthly frequency, 3-5 days in duration of periods, normal amount of bleeding; denies bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension, denies Vaginal discharge, itching, sores, lumps, sexually transmitted infection, and treatments. Sexual interest, satisfaction, denies pain during intercourse (dyspareunia)

Musculoskeletal: Denies Muscle or joint pain, stiffness, arthritis, gout, backache. Denies Neck or low back pain or Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness.

Psychiatric: Denies nervousness, tension, mood disorders, including depression, denies memory change, suicidal ideation, suicide plans or attempts.

Neurologic: denies Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness, loss of sensation, tingling or “pins and needles,” ( Paresthesia) tremors or other involuntary movement seizures.

Hematologic: Denies Anemia, easy bruising, or bleeding

Endocrine: Denies Heat or cold intolerance, excessive sweating ,excessive thirst (polydipsia), hunger (polyphagia), or urine output (polyuria).


PHYSICAL EXAMINATION



General survey: Julia is tall, overweight, 35-year-old African American female, who appears stated age she is alert and oriented x 3, as appropriate affect, and well-dressed.




Vital signs: Height (without shoes) 172.7 cm (5’8”) Weight (dressed) 77.1kg (170lbs). BMI 25.85 kg / m2 (overweight). Temperature (oral) 99.8 °F, Heart Rate (HR) 109 and regular, Blood Pressure (BP) 150/68 right arm supine, Respiration Rate (RR) 14, Pulse oximetry 100% in Room Air,




Skin: Skin is warm, dry, and intact, no rashes or lesions, palms warm, dry with good color, Nails without clubbing, cyanosis.




Head, Eyes, Ears, Nose, Throat (HEENT): Head: Hair is average texture, scalp without lesions, Normocephalic/atraumatic (NC/AT)
Eyes: Vision 20/20 in each eye without correction, visual fields full by confrontation. Conjunctiva pink; sclera white. Pupils 4mm constricting to 2 mm, round, regular, equally reactive to light. Extraocular movements intact. Disc margins sharp, without hemorrhage, exudate. No arteriolar narrowing or A-V nicking.
Ears: Left canal clear, tympanic membrane (TM) intact pearly gray with cone of light 5 o’clock. Right ear, canal clear, tympanic membrane (TM) intact pearly gray with cone of light 7 o’clock Acuity good to whispered voice. Weber midline. AC> BC bilaterally.
Nose: Mucosa pink, septum midline. No sinus tenderness, No nasal polyps or discharge.
Mouth: oral mucosa pink, moist, and intact, Dentition is good, Tongue midline with strawberry patches. Tonsils are abnormal. Pharynx with bilateral tonsillar exudates, 3+R, 2+L. Uvula midline and edematous

Neck: Neck supple. Trachea midline. Thyroid without nodule or goiter

Lymph nodes: Bilateral cervical lymphadenopathy noted to palpation., No axillary, or epitrochlear nodes.

Thorax and lungs: Posterior thorax elliptical in shape, symmetrical with good excursion , no rashes or lesions noted, skin is intact, anterior-posterior (A/P) diameter is 2:1, chest wall without pain to palpation, Tactile fremitus is negative, Lungs resonant on percussion. Breath sounds vesicular with no added sounds to auscultation, No egophony, bronchophony, or whispered pectoriloquy. Diaphragms descend 4 cm bilaterally to level of cervical vertebrae 8(C8) anteriorly, to thoracic vertebrae 10 (T10) posteriorly.

Cardiovascular: Jugular venous pressure 1 cm above the sternal angle, with the head of the examining table raised to 30 degrees. Carotid upstrokes brisk, without bruits. Point of maximal impulse discrete and tapping, barely palpable in the 5th left interspace, 8 cm lateral to the midsternal line. Good S1, S2. No murmur auscultated, no splitting of S3 or S4, No orthopnea, palpitations, or dyspnea.

Breasts: Pendulous, symmetric. No masses; nipples without discharge.

Abdomen: soft, nontender to palpation, stomach tympanic to percussion, Bowel sounds active x 4. No tenderness or palpable masses. Liver span 7cm in right midclavicular line; edge smooth, palpable 1 cm below right costal margin (RCM). no Splenomegaly. No costovertebral angles tenderness (CVAT).

Genitalia: External genitalia without lesions. Mild cystocele at introitus on straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge. Uterus anterior, midline, smooth, not enlarged . Adnexa is not palpated due to obesity and poor relaxation. No cervical or Adnexal tenderness. Pap Smear taken. Rectovaginal wall intact.



Rectal: No external hemorrhoids, tight sphincter tone, rectal vault without masses, stool brown negative for occult blood.

Extremities: Bilateral upper extremities warm. Bilateral lower extremities; no edema. Calves supple, symmetric, temperature intact bilaterally with negative Homan’s sign.



Peripheral vascular: No varicosities in lower extremities. No stasis pigmentation or ulcers Pulses. (2+ = normal)

_________________________________________________________        

Radial           Femoral      Popliteal       Dorsalis Pedis    Posterior Tibial

_________________________________________________________

Rt              2+                  2+                2+                      2+                       2+

_________________________________________________________ LT              2+                 2+                2+                       2+                      2+

_________________________________________________________

Musculoskeletal: No joint deformities or selling on inspection and palpation. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles.

Neurologic: Mental Status:  Alert and cooperative. Thought processes are coherent and insight is good. Oriented to person, place, and time. Cranial
nerves: II to XII intact.
Motor: Good muscle bulk and tone.
Strength: 5/5 bilaterally in deltoids, biceps, triceps, hand grips, iliopsoas, hamstrings, quadriceps, tibialis anterior, and gastrocnemius.
Cerebellar: Rapid Alternating movements (RAMs)  and point-to-point movements intact. Gait stable, fluid.
Sensory:  Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative.



Reflexes: Bilateral triceps, brachioradialis, patellar and Achilles deep tendon reflexes intact. Bilateral plantar reflex intact. Babinski response is negative.


DIFFERENTIAL DIAGNOSIS

Diagnosis #1: Bacterial pharyngitis

Pathophysiology: With the aid of adhesins on the organism’s surface, bacteria adhere to the pharyngeal mucosa in the pathogenesis of GAS in the throat. It then produces several proteases and cytolysins, which penetrate the mucosal tissue and cause inflammation that manifests as pharyngitis symptoms such as fever, exudates, swelling, and pain with swallowing (Wolford et al., 2018).

Etiology: Bacterial pharyngitis is an infection of the oropharynx caused by S. pyogenes. which is transmitted via ingestion or airborne transmission.

Diagnostic criteria: Diagnostic evaluation of bacterial pharyngitis is done by either rapid antigen detection test or a throat culture (Luo et al., 2019).

Throat culture continues to be the gold standard for the diagnosis of streptococcal pharyngitis. Under ideal conditions, the sensitivity of throat culture for group A beta-hemolytic streptococci.

A rapid antigen detection test (rapid strep test) can be completed in the office setting, with results accessible within five to ten minutes.

Unusual
Clinical findings: sore throat, temperature greater than 100.4°F (38°C), tonsillar exudates, Cough, pain when swallowing, edematous vulva, tonsillar hypertrophy and inflammation, swollen pharynx, and cervical lymphadenopathy.

Pertinent positives:

· Positive: Fever, sore throat, tender anterior cervical adenopathy, pain with swallowing, pharyngeal tonsillar exudate

Pertinent negatives:

· Negative: splenomegaly, transient upper lid edema (Hoagland sign), sandpaper rash, flushed face with circumoral pallor.

Treatment Plan: Pharyngitis; penicillin or amoxicillin are the recommended treatments. Clindamycin, clarithromycin, or azithromycin can be used for people who are allergic to penicillin. Only in specific patient populations is a test of cure advised; it should not be used frequently (Ashurst & Edgerley-Gibb, 2022).

Plan of care

Pharmacology

· Penicillin V potassium, 250 mg orally, three times a day for 10 days

· Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to lower the fever and provide pain relief for the sore throat, as needed

· Albuterol 2.5 mg via nebulizer as needed

Non-pharmacology

· Recommend that patient follow a good hand hygiene, wash hands before/ after handling food or touching face

· Recommend that patient avoid sick contact, and crowed place; if necessary, cover nose and mouth with a mask.

· Encourage patients to take a few days off from work and have a good rest

· Perform either a rapid antigen detection test (RADT) or throat culture as indicated

· Encourage hydration.

Patient Education.

Patients with streptococcal pharyngitis are considered contagious until they have been taking an antibiotic for 24 hours

Educating patients to rinse toothbrushes and removable orthodontic appliances thoroughly can help to prevent recurrent infections.

Educate patients to complete the whole dose of antibiotic even if they feel better.

Follow up

· Routine post-treatment throat cultures are not necessary. About 5 to 12 percent of treated patients have a positive post-treatment culture, regardless of the therapy given (Hayes & Williams, 2022).

· Patient may return to clinic if pharyngitis is not resolve or exceed 10 days or with other severe compilations (Otitis media, post-streptococcal glomerulonephritis, rheumatic fever).

Diagnosis #2: Tonsillitis

Pathophysiology and Etiology: Tonsillitis is an inflammation of the pharyngeal tonsils. Inflammation can also affect other areas of the back of the throat, including the adenoids and the lingual tonsils. When a bacterial or viral disease invades the tonsils and causes an inflammatory reaction, tonsillitis results (Anderson & Paterek, 2022). It manifests as a result of viruses invading the tonsils, which trigger an inflammatory reaction with elevated cytokines which results in symptoms such as Sore throat, pain on swallowing, Fever, tonsillar exudate, and cough (Bakar, 2018).

Diagnosis #2: Infectious mononucleosis

Pathophysiology and Etiology: Atypical lymphocytes are mostly produced by CD8+ T cells that react to the infection. Following primary infection, EBV is permanently present in the host, particularly in B cells, and periodically sheds asymptomatically from the oropharynx (Mohseni, et al., 2022). The human herpesvirus type 4 Epstein-Barr virus (EBV) is the cause of infectious mononucleosis, which is characterized by tiredness, fever, pharyngitis, and lymphadenopathy. Rarely, severe side effects such airway blockage, splenic burst, and neurologic disorders develop. infection is unusually long, lasting around six weeks. Diagnosis is typically done by heterophile antibody tests and/or EBV-specific antibody tests (Dunmire et al., 2018).


ADDITIONAL HISTORY DATA TO SUPPORT PRIMARY DIAGNOSIS

1.Do you have any breathing problems?- The germs that cause infectious pharyngitis can generate a local inflammatory response that might cause airway blockage.

2. do you often feel tired and exhausted?- bacterial pharyngitis may make a person feel tired and exhausted often

3. do you experience any abdominal pain of feeling nauseated or vomit?- these are common symptoms of Pharyngitis.

4. have you found yourself among crowds of people recently?-.Pharyngitis can be acquired in crowdy areas.

5. did you eat anything you have not eaten before in the past week?- sometimes pharyngitis occurs because of mishandling of food.

6. did you come in contact with a person known to have sore throats recently?- pharyngitis can be acquired through personal contact.

7. have you experienced symptoms of conjunctivitis or a runny nose?- these are also additional symptoms of Group Pharyngitis

8. do you experience body aches?- with Pharyngitis it is common to have body aches

9. does your body shake and feel extremely cold?- Pharyngitis can also cause extreme colds,

10. has your appetite changed recently?- loss of appetite is also common due to viral infection


ADDITIONAL PHYSICAL COMPONENTS TO SUPPORT PRIMARY DIAGNOSIS

· Fatigue- a patient with Pharyngitis often experiences general fatigue

· Lymphadenopathy on palpation- pharyngitis is also associated with cervical lymphadenopathy

· tongue with strawberry patches- palatal petechiae is associated with this sign and is common with Pharyngitis.

· problem with swallowing due to pain and does not improve even with medication- Pharyngitis is associated with a persistent sore throat.

· Sore throat is a typical symptom of Group A streptococcal pharyngitis



Family History Genogram


Mother -65, Alive, HTN,HLD,CVA

alive

Father-68, Alive, CAD, HTN,HLD, DM

Julie-35, HTN, Asthma

Husband- 39, Alive, HTN

Son-3 Alive, Asthma

aa



Indicates Patient

Living female

Living male

References


Bakar, M. A., McKimm, J., Haque, S. Z., Majumder, A., & Haque, M., (2018) Chronic tonsillitis and biofilms: a brief overview of treatment modalities,
Journal of Inflammation Research, 11:, 329-337, DOI: 10.2147/JIR.S162486

Dunmire, S. K., Verghese, P. S., & Balfour, H. H. (2018) Primary Epstein-Barr virus infection:
Journal of Clinical Virology. Volume 102, Pages 84-92,


Hayes, C. S., & Williamson, H. Jr., (2002) Management of Group A beta-hemolytic streptococcal pharyngitis.
American Family Physician, 63(8):1557-64.



https://doi.org/10.1016/j.jcv.2018.03.001

Luo, R., Sickler, J., Vahidnia, F., Lee, Y. C., Frogner, B., & Thompson, M. (2019). Diagnosis and management of group A streptococcal pharyngitis in the United States, 2011–2015. 
BMC infectious diseases
19(1), 1-9.

Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T., & Beyea, J. A. (2020). Pharyngitis: approach to diagnosis and treatment. 
Canadian Family Physician
66(4), 251-257.


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“If the finding is normal put “denies”. If it is abnormal put “endorses”.

Use the pocket manual for differential diagnosis to look up your symptoms (presenting) and they will list possible causes. Narrow the causes down based on 1)your patient’s presenting symptoms and 2) by using the current medical diagnosis and treatment textbook.

Create a genogram for the family history.

Look at the case study rubric and make sure you’ve met all requirements.

Pertinent positive: sign/symptom that helps to rule in diagnosis.

Pertinent negative: sign/symptom that is NOT present and because it is not present helps to rule out an alternate diagnosis.

For example, pertinent positives for pneumonia could be fever and cough with blood-tinged sputum. These could also be pertinent positives for TB but if the patient does NOT have night sweats and weight loss for example, the absence of these symptoms would be pertinent negatives that would make you think the patient is more likely experiencing pneumonia (rule out TB).

Case Study 1

Criteria

Ratings

Pts

This criterion is linked to a Learning Outcome Differential Diagnoses

30 to >26.4 pts

Distinguished

Prioritizes at minimum 3 related differential diagnoses with applicable
rationale including pertinent positives and negatives.

26.4 to >22.8 pts

Proficient

Prioritizes at minimum 2 accurate, related differential diagnoses with applicable rationale including pertinent positives and negatives.

22.8 to >20.4 pts

Emerging

Includes only 1 accurate, related differential diagnosis with applicable rationale including pertinent positives and negatives.

20.4 to >0 pts

Not evident

Incorrect and unprioritized differentials without rationales and/or pertinent positives and negatives

30 pts

This criterion is linked to a Learning Outcome Writing Mechanics / Citations

15 to >12.0 pts

Distinguished

No errors related to organization, grammar and style, and citations. APA 7 format

12 to >9.0 pts

Proficient

Minor errors related to organization, grammar and style, and citations. APA format with minor errors

9 to >8.0 pts

Emerging

Some errors related to organization, grammar and style, and citations. APA 7 format with multiple errors

8 to >3.0 pts

Not evident

Major errors related to organization, grammar and style, and citations. Improper citations and format

3 to >0 pts

No marks

Poorly organized details and grammatical errors without citations and improper format

15 pts

This criterion is linked to a Learning Outcome Research

15 to >13.0 pts

Distinguished

Incorporates several applicable scholarly resources effectively that reflect depth and breadth of research.

13 to >11.0 pts

Proficient

Incorporates some applicable scholarly resources effectively that reflect depth and breadth of research.

11 to >10.0 pts

Emerging

Incorporates very few applicable scholarly resources that reflect depth and breadth of research.

10 to >4.0 pts

Not evident

Does not incorporate scholarly resources that reflect depth and breadth of research

4 to >0 pts

Not evident

No referenced articles

15 pts

This criterion is linked to a Learning Outcome Critical Thinking

20 to >15.0 pts

Distinguished

Draws insightful conclusions to create an evidence-based treatment plan with clear cited rationales
considering social determinants of health.

15 to >10.0 pts

Emerging

Clear and thoughtful treatment plan with or without fully referenced rationales and consideration for social determinants of health with minor errors

10 to >5.0 pts

Emerging

Adequate treatment plan with referenced rationales and fair consideration for social determinants of health

5 to >0.0 pts

Not evident

Incomplete treatment plan without referenced rationales or consideration for social determinants of health

0 pts

No marks

Absent details

20 pts

This criterion is linked to a Learning Outcome Education, Follow up and Collaboration

20 to >10.0 pts

Distinguished

Student provides thorough education regarding
treatment plan with appropriate follow up and lists appropriate and reasonable groups for collaboration

10 to >8.0 pts

Proficient

Student provides minimum education regarding treatment plan with vague follow up and lists inappropriate groups for collaboration

8 to >5.0 pts

Emerging

Limited education or explanation related to treatment plan with inaccurate follow up and inaccurate collaborative groups

5 to >0.0 pts

Emerging

Poor education, No follow up and no collaborative groups

0 pts

No Marks

Absent details

20 pts

Total Points: 100

Case Study 1

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