Week 3 Peer Case Study Assignment

Week 3 Peer Case Study Assignment

Week 3 Peer Case Study Assignment

Primary diagnosis #1 Infectious Mononucleosis- Rationale with Pertinent positives findings, diagnostics test and treatment,
#2 – strep throat Pertinent positives findings, diagnostics test and treatment,
#3 Pharyngitis- Pertinent positives findings, diagnostics test and treatment,

WEEK 3 PEER CASE STUDY #2

Chief Complaint– sore throat

History of Present Illness- The patient is an eleven-year-old male that presents with lethargy, fatigue, body aches, sore throat, and a mild fever for five days. No ear pain is present. The patient reports a decreased appetite and has only been consuming liquid over the past two days. The patient has been out of school for the past two days due to a fever. He has taken Tylenol every four hours for pain and fever reduction with good effect.

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The patient has no medical or surgical history. Patient has no allergies and takes no medication daily.

ROS-

General- Patient is comfortable and in no acute distress. Patient is reporting fatigue, headache, and generalized body aches.

HEENT- Headache reported. Patient denies eye pain or drainage, loss of eyesight, nasal congestion, nasal pain, ear pain, or decreased hearing. Patient reports throat pain.

Respiratory- Patient denies shortness of breath, cough, or pain on inspiration. No wheezing is present.

Cardiovascular- No chest pain reported.

Gastrointestinal- No abdomen pain reported. Normal bowel movements. Tenderness reported in the left quadrant below the ribs.

Genitourinary- No pain on urination. Urine is reported by patient to be dark amber in color, clear, and with no odor.

Musculoskeletal- No pain on range of motion.

Neurology- Headache reported. No dizziness, numbness or tingling reported.

Objective findings:

Vital signs- BP 100/60, Pulse 101, SP02 98%, Respirations 18, and Temperature 100 degrees F. Height is 56 inches. Weight is 82lbs. BMI 18.4. Growth chart- 27^th percentile in height and the 43^rd percentile for weight. Tanner stage- 2

Physical findings- Patient is awake and alert to person, place, and time. Head is normocephalic, trachea is midline and with no deviations. Eyes are equal bilateral. Bilateral eyes are clear with no redness or discharge present. PEERLA. Ears are equal bilateral. Bilateral ear canals are clear with bilateral pearly grey tympanic membranes. Nose is midline with no drainage or congestion within the nasal cavity. Heart rate regular. S1 and S2 present. No swelling reported in extremities. Lung sounds are clear on auscultation in all fields. Bowel sounds are active in all quadrants. The throat is reddened with no discharge noted. The bilateral tonsils are swollen, reddened, and are a grade 3 on the Brodsky grading scale. The bilateral, anterior cervical lymph nodes are swollen and tender. The abdomen flat and non-distended. Tenderness is noted around the spleen. The spleen is noted to be swollen on deep palpation. Otherwise, no tenderness noted in the abdomen. The patient has full range of motion in all extremities. No swelling noted in the upper or lower extremities. Radial and pedal pulses are 2+ and bounding.

Diagnostic Testing– A complete blood count (CBC) was obtained and showed:

WBC 15

RBC 5

Hemoglobin 14 g/dl

Hematocrit 43%

Platelets 300