Case #92: Say Ahhhh! BY AMI ALANIZ

Gross Overview Note the: Soft palate: general appearence Tonsil: size and general appearance

The Patient

Profile  female  11 years old  Caucasion

Past Medical History  Ear 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 6 th 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  chills  pain with swallowing

Testing

Terms to Know o edema o swelling o general response to injury or inflammation o erythema o redness o results from capillary congestion o exudate o a “mass of cells and fluid that seep out of blood vessels or organs” o especially prevalent in inflammation

Testing, Testing!  Vital Signs  temperature: 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 Results HB 13.2 g/dLNeutrophils 72%Basophils 1% Hct 43.9%Lymphocytes 21%ESR 18 mm/hr Plt 390,000/mm^3Monocytes 5%CRP 2.3 mg/dL WBC 15,500/mm^3Eosinophils 1%(+) Rapid streptococcal antigen test

Case Question #1: Answered  fever  Warm skin  Pale skin  Absence of rash  Tonsillar edema  Tonsillar erythema with yellow-white exudate  soft palate erythema  prominent “strawberry” tongue  white blood cell count  neutrophils  lymphocytes  “strep has been going around school for the past two weeks”  participation in sports (presumably at school)  chills  lack of appetite  tiredness  possible weak immune system  pain with swallowing  tender with palpitation lymph nodes

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