Download Case 92

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 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 betahemolytic 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 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: 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 Results
HB
Hct
Plt
WBC
13.2 g/dL Neutrophils
43.9% Lymphocytes
390,000/mm^3 Monocytes
15,500/mm^3 Eosinophils
72% Basophils
1%
21% ESR
18 mm/hr
5% CRP
2.3 mg/dL
1% (+) Rapid streptococcal
antigen test
Case Question #1: Answered
 fever
 Warm skin
 Pale skin
 Absence of rash
 Tonsillar edema
 prominent “strawberry”  chills
tongue
 lack of appetite
 white blood cell count
 tiredness
 neutrophils
 possible weak immune
 lymphocytes
system
 “strep has been going
 pain with swallowing
 Tonsillar erythema with around school for the past
yellow-white exudate
 tender with palpitation
two weeks”
lymph nodes
 soft palate erythema
 participation in sports
(presumably at school)
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