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