Adam I: sore throat

Immune System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P19_F1.jpg"}},{"insert":"\n\n"},{"insert":"Having ran 5 km at the gym before breakfast, you start your morning shift at the ED with the feeling that it\u0027s going to be a great day.\n\nAs you are sipping on your protein shake proudly, you are handed the file of a patient who just arrived in the ED and is waiting for you to see him.\n\nHis name is Adam McGlynn and he is a 15-year-old high-schooler who says, \u201cI woke up early this morning and was heading out for training, but I felt bad so I came here instead...\u201d\n\n\u201cYou work out this early in the day?\u201d you ask with a smile. Adam responds: \u201dOf course. I\u2019m the captain of my school\u2019s rugby team.\u201d\n\nFeeling a bit intimidated, you go to take a focused history.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P19_F2.jpg"}},{"insert":"\n\n"},{"insert":"Adam complains of fever, a sore-throat, and lack of energy, all since waking up today.\n\nHe has no other illnesses, is not on any medications, is fully immunized, has no allergies, and doesn\u2019t drink alcohol, smoke or take drugs. There is no history of travel or exposure to animals.\n\nOn examination, his temperature is 38.9 \u00b0C (102.02 \u00b0F), blood pressure is 110\/70 mmHg, pulse is 72 beats\/min, and respiratory rate is 14\/min.\n\nInspection of the throat shows multiple whitish blotches over enlarged tonsils. There is bilateral tender cervical lymphadenopathy. Cardiorespiratory and abdominal examination is normal.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P19_F3.jpg"}},{"insert":"\n\n"},{"insert":"Based on the Centor criteria, you realize that Adam has \u003E50% probability for Streptococcal pharyngitis. You then perform a rapid strep test, which is positive.\n\nSubsequently, you obtain throat swab samples for culture. You also prescribe a course of oral penicillin for 10 days, along with analgesics. You then send Adam home, but ask him to come back if he starts feeling worse.\n\n\u0022Well, hopefully, the antibiotics will fix it, Doctor! Thank you so much!\u0022 he says, and leaves the ED.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P19_F4.jpg"}},{"insert":"\n\n"},{"insert":"Around 3 days later, Adam\u0027s throat culture results come in. As expected, they show growth of group A beta-hemolytic Streptococcus (GAS). Since you\u0027ve already started him on penicillin, you make a note in his medical record and ask your staff to follow-up once the course is complete.\n\nHowever, just 2 days afterward, you are surprised to see Adam once again - this time accompanied by his mother. You find out that she is Dr. McGlynn, a very experienced family practice physician.\n\nShe tells you that Adam\u0027s fever and sore throat have persisted since the day you first saw him (a total of 6 days so far). He also developed a rash and abdominal discomfort yesterday.\n\nExamination shows that the tonsils are still enlarged and covered with a white-grayish exudate. Posterior palatine petechiae are also present now. The rash is generalized and maculopapular. Cardiorespiratory examination is normal, but on abdominal examination you detect mild splenomegaly.\n"}]}


{"ops":[{"insert":"What is your provisional diagnosis?\n"}]}
1. Influenza
2. Infectious mononucleosis
3. Acute rheumatic fever