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CASE STUDY: Infectious Mononucleosis PATIENT INFORMATION: L. A. is a 25-year-old, Male. CHIEF COMPLAINT: Sore throat. HISTORY OF PRESENT ILLNESS: Onset: Patient stated that illness started 7 (seven) days ago. Location: Throat. Duration: Developed Seven days ago prior to his visit with low (99.0F) to moderate grade fever (101.1F) fever. Characteristics: Patient stated that he had fever no greater than 101.1F, associated with swollen and tender glands. Patient denied Cough, lost his appetite. Patient noticed yesterday for the first time that his eyes and skin were yellow. Patient also stated that his upper abdomen is swollen without any pain, nausea, vomiting or change in bowel movements. Aggravating/Associated Factors: Not known. Relieving Factors: Not known. Treatment: Not known. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: Patient denied any history of jaundice, hepatitis, blood transfusion, body piercing, tattoos or eating shellfish. He also denies of taking any medications. Patient received Hepatitis B vaccination. SURGICAL HISTORY: Patient denies any previous surgery. FAMILY HISTORY: Family history is non-contributory. SOCIAL HISTORY: Patient is a college student, sexually active, in a monogamous relationship heterosexual, has one girlfriend of 2 years who is experiencing similar symptoms and claims to use condom always. Patient had 2 previous partners. Patient denies drinking, smoking, or using an illicit drug. Patient does not take any medications. He has not traveled recently. Patient received Hepatitis B vaccination prior to starting college. REVIEW OF THE SYSTEMS: Constitutional: Patient is well developed, appears to be in no acute distress but seems to be concerned and anxious. No weight loss, (+) low grade to moderate grade fever (99.0F- 101.1F), no chills, (+) weakness and fatigue. Skin: Changed to yellow color, no rashes, no itching, no change in nails, and no hair loss or change in texture. HEENT: No headache, no vertigo, dizziness or lightheadedness, no blurring of vision, no double vision, no tearing, no ringing in the ears, No ear pain/discharge bilaterally, (+) sore throat worst with swallowing, (+) tender and swollen neck glands, no neck pain. Cardiovascular: No chest pain, no palpitation noted. Respiratory: No shortness of breath or cough. Gastrointestinal: (+) loss of appetite due to difficulty swallowing, no nausea, no vomiting, and no change in bowel movement habits. Genitourinary: No pain in urination, no changes in urination pattern. Neurologic: No problems with speech, memory, and motor coordination, no numbness or tingling sensation. Musculoskeletal: No muscular weakness or cramps, no joint pain, no muscles pain or tenderness. Hematologic: No bruises, no petechiae noted, no anemia, bleeding. Psychiatric: No change in mood or orientation. Endocrine: No polyuria or polydipsia. No report of sweating, cold or heat intolerance. Allergies: No known allergy. PHYSICAL EXAMINATION: General: Patient is well developed, awake, alert and appears to be in no acute distress but seems anxious and concerned. Vital signs: BP – 130/80, PR- 110/min, RR – 20/min, T – 101.4 F, SpO2 – 99%. Skin: Moist, no rashes, no bruising. HEENT: PERRLA (pupils equal and reactive to light and accommodation), EOMI, icteric sclerae, pink conjunctivae, Tonsillo-pharyngeal area erythematous with exudate. Neck: Posterior cervical lymph nodes swollen, tender and movable, bilaterally. Supraclavicular lymph nodes not enlarged. Heart- PMI palpable in the left 5th intercostal space, midclavicular line, tachycardia, rate is regular, rhythm is normal, no murmur noted. Thorax and Back: Symmetrical chest expansion with breathing. No costovertebral angle tenderness. No spinal tenderness. Lungs: Normal resonance on percussion, clear and equal breath sounds, no crackles, no wheezing, or rhonchi. Abdomen: Normal bowel sounds, splenomegaly -14cm in midclavicular line noted on percussion. Diffused abdominal tenderness in both right and left upper quadrants noted on palpation. Extremities: No cyanosis, no clubbing of the nails, no edema, normal range of motion, pulses present with regular rhythm. Neurologic: Patient is awake, alert, oriented to person, place and time, cranial nerves intact, normal muscle tone, sensation intact, deep tendon reflexes are 2/4, no problems with motor coordination. ASSESSMENT: Primary Diagnosis: The patient’s clinical symptoms suggest an Infectious Mononucleosis also called mono or Kissing disease. Epstein- Barr virus (EBV) is the most common cause of infectious mononucleosis. On physical examination of the patient’s neck, the posterior cervical lymph nodes are swollen, and the Tonsillo-pharyngeal area erythematous with exudate. Infectious mononucleosis is common among teenagers and young adults, especially college students. The disease spreads through bodily fluids, especially saliva but can also spread through blood, semen or organ transplantations. It’s incubation period is between 4-8 weeks with symptoms after the first 3 days of exposure. Most common symptoms include; fever, sore throat, swollen lymph nodes in the neck and arm pits, fatigue, swollen liver or spleen or both which the patient and his girlfriend are both experiencing. Management of IM is usually supportive and can be ruled out by doing a peripheral smear looking for the presence of atypical lymphocytes and doing a heterophile antibody test (Luzuriaga & Sullivan, 2010). DIFFERENTIAL DIAGNOSIS: 1. Gilbert syndrome: Gilbert’s syndrome, the liver doesn’t properly process bilirubin which is produced by the breakdown of red blood cells. Thereby causing the skin and the whites of the eyes to have a yellowish tinge (jaundice), which is as a result of the slightly elevated levels of bilirubin in the blood (Domino, Baldor, & Golding, 2015). This can be ruled out by doing CBC and liver function test. A combination of normal blood and liver function tests and elevated bilirubin levels is an indicator of Gilbert’s syndrome. Genetic testing usually confirms the diagnosis. (Luzuriaga & Sullivan, 2010). 2. Hepatitis C is a viral infection that causes liver inflammation, sometimes leading to serious liver damage. The hepatitis C virus (HCV) spreads through contaminated blood and can cause both acute and chronic hepatitis. The acute process is self-limited, rarely causes hepatic failure and usually leads to chronic infection. However, the chronic HCV infection often follows a progressive course over many years which can ultimately result in cirrhosis, hepatocellular carcinoma, and the need for liver transplantation (William & Hopper 2011). PLAN: Diagnostic: Liver Function Test (LFT), Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) Hepatitis Panel, Ultrasound, Rapid Strep Test/Throat Culture, Monospot test. SCREENING: None Medical treatment (Rx): The treatment is supportive. Patients are encouraged to rest during the acute phase but can resume activity when fever, pharyngitis, and malaise abate. To prevent splenic rupture, patients should avoid heavy lifting and contact sports for 1 month after presentation and until splenomegaly (which can be monitored by ultrasonography) resolves. EDUCATION/HOME REMEDIES: There is no vaccine to protect against mononucleosis. To prevent the of disease, people should avoid kissing or sharing drinks or personal items with people who have the disease. Contact sport should be avoided since the liver or spleen may be swollen which may cause rupture. Inform the patient that signs and symptoms of infection include fever, chills, sore throat, enlarged lymph nodes, and fatigue. Emphasize the importance of self-care while the disease runs its course, which includes adequate fluid and nutritional intake along with sufficient rest. Patient is encouraged/instructed to use (over the counter) OTC ibuprofen or Tylenol to reduce fever. (Kormos, W. 2014). CONSULT/REFERRAL: Patient to consult provider if fluctuant fever or new symptoms appear such as nausea, vomiting, abdominal pain, neck stiffness, swollen testicles, skin rash, increased fatigue, cough or shortness of breath. (Rana, R. S., & Moonis, G. 2015). FOLLOW-UP: In the event of worsening symptoms or onset of new symptoms, patient is advised to seek medical assistance immediately.

CASE STUDY: Infectious Mononucleosis PATIENT INFORMATION: L. A. is a 25-year-old, Male. CHIEF COMPLAINT: Sore throat. HISTORY OF PRESENT ILLNESS: Onset: Patient stated that illness started 7 (seven) days ago. Location: Throat. Duration: Developed Seven days ago prior to his visit with low (99.0F) to moderate grade fever (101.1F) fever. Characteristics: Patient stated that he had fever no greater than 101.1F, associated with swollen and tender glands. Patient denied Cough, lost his appetite. Patient noticed yesterday for the first time that his eyes and skin were yellow. Patient also stated that his upper abdomen is swollen without any pain, nausea, vomiting or change in bowel movements. Aggravating/Associated Factors: Not known. Relieving Factors: Not known. Treatment: Not known. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: Patient denied any history of jaundice, hepatitis, blood transfusion, body piercing, tattoos or eating shellfish. He also denies of taking any medications. Patient received Hepatitis B vaccination. SURGICAL HISTORY: Patient denies any previous surgery. FAMILY HISTORY: Family history is non-contributory. SOCIAL HISTORY: Patient is a college student, sexually active, in a monogamous relationship heterosexual, has one girlfriend of 2 years who is experiencing similar symptoms and claims to use condom always. Patient had 2 previous partners. Patient denies drinking, smoking, or using an illicit drug. Patient does not take any medications. He has not traveled recently. Patient received Hepatitis B vaccination prior to starting college. REVIEW OF THE SYSTEMS: Constitutional: Patient is well developed, appears to be in no acute distress but seems to be concerned and anxious. No weight loss, (+) low grade to moderate grade fever (99.0F- 101.1F), no chills, (+) weakness and fatigue. Skin: Changed to yellow color, no rashes, no itching, no change in nails, and no hair loss or change in texture. HEENT: No headache, no vertigo, dizziness or lightheadedness, no blurring of vision, no double vision, no tearing, no ringing in the ears, No ear pain/discharge bilaterally, (+) sore throat worst with swallowing, (+) tender and swollen neck glands, no neck pain. Cardiovascular: No chest pain, no palpitation noted. Respiratory: No shortness of breath or cough. Gastrointestinal: (+) loss of appetite due to difficulty swallowing, no nausea, no vomiting, and no change in bowel movement habits. Genitourinary: No pain in urination, no changes in urination pattern. Neurologic: No problems with speech, memory, and motor coordination, no numbness or tingling sensation. Musculoskeletal: No muscular weakness or cramps, no joint pain, no muscles pain or tenderness. Hematologic: No bruises, no petechiae noted, no anemia, bleeding. Psychiatric: No change in mood or orientation. Endocrine: No polyuria or polydipsia. No report of sweating, cold or heat intolerance. Allergies: No known allergy. PHYSICAL EXAMINATION: General: Patient is well developed, awake, alert and appears to be in no acute distress but seems anxious and concerned. Vital signs: BP – 130/80, PR- 110/min, RR – 20/min, T – 101.4 F, SpO2 – 99%. Skin: Moist, no rashes, no bruising. HEENT: PERRLA (pupils equal and reactive to light and accommodation), EOMI, icteric sclerae, pink conjunctivae, Tonsillo-pharyngeal area erythematous with exudate. Neck: Posterior cervical lymph nodes swollen, tender and movable, bilaterally. Supraclavicular lymph nodes not enlarged. Heart- PMI palpable in the left 5th intercostal space, midclavicular line, tachycardia, rate is regular, rhythm is normal, no murmur noted. Thorax and Back: Symmetrical chest expansion with breathing. No costovertebral angle tenderness. No spinal tenderness. Lungs: Normal resonance on percussion, clear and equal breath sounds, no crackles, no wheezing, or rhonchi. Abdomen: Normal bowel sounds, splenomegaly -14cm in midclavicular line noted on percussion. Diffused abdominal tenderness in both right and left upper quadrants noted on palpation. Extremities: No cyanosis, no clubbing of the nails, no edema, normal range of motion, pulses present with regular rhythm. Neurologic: Patient is awake, alert, oriented to person, place and time, cranial nerves intact, normal muscle tone, sensation intact, deep tendon reflexes are 2/4, no problems with motor coordination. ASSESSMENT: Primary Diagnosis: The patient’s clinical symptoms suggest an Infectious Mononucleosis also called mono or Kissing disease. Epstein- Barr virus (EBV) is the most common cause of infectious mononucleosis. On physical examination of the patient’s neck, the posterior cervical lymph nodes are swollen, and the Tonsillo-pharyngeal area erythematous with exudate. Infectious mononucleosis is common among teenagers and young adults, especially college students. The disease spreads through bodily fluids, especially saliva but can also spread through blood, semen or organ transplantations. It’s incubation period is between 4-8 weeks with symptoms after the first 3 days of exposure. Most common symptoms include; fever, sore throat, swollen lymph nodes in the neck and arm pits, fatigue, swollen liver or spleen or both which the patient and his girlfriend are both experiencing. Management of IM is usually supportive and can be ruled out by doing a peripheral smear looking for the presence of atypical lymphocytes and doing a heterophile antibody test (Luzuriaga & Sullivan, 2010).

DIFFERENTIAL DIAGNOSIS:

1. Gilbert syndrome: Gilbert’s syndrome, the liver doesn’t properly process bilirubin which is produced by the breakdown of red blood cells. Thereby causing the skin and the whites of the eyes to have a yellowish tinge (jaundice), which is as a result of the slightly elevated levels of bilirubin in the blood (Domino, Baldor, & Golding, 2015). This can be ruled out by doing CBC and liver function test. A combination of normal blood and liver function tests and elevated bilirubin levels is an indicator of Gilbert’s syndrome. Genetic testing usually confirms the diagnosis. (Luzuriaga & Sullivan, 2010).

2. Hepatitis C is a viral infection that causes liver inflammation, sometimes leading to serious liver damage. The hepatitis C virus (HCV) spreads through contaminated blood and can cause both acute and chronic hepatitis. The acute process is self-limited, rarely causes hepatic failure and usually leads to chronic infection. However, the chronic HCV infection often follows a progressive course over many years which can ultimately result in cirrhosis, hepatocellular carcinoma, and the need for liver transplantation (William & Hopper 2011).

PLAN: Diagnostic: Liver Function Test (LFT), Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) Hepatitis Panel, Ultrasound, Rapid Strep Test/Throat Culture, Monospot test. SCREENING: None Medical treatment (Rx): The treatment is supportive. Patients are encouraged to rest during the acute phase but can resume activity when fever, pharyngitis, and malaise abate. To prevent splenic rupture, patients should avoid heavy lifting and contact sports for 1 month after presentation and until splenomegaly (which can be monitored by ultrasonography) resolves.

EDUCATION/HOME REMEDIES: There is no vaccine to protect against mononucleosis. To prevent the of disease, people should avoid kissing or sharing drinks or personal items with people who have the disease. Contact sport should be avoided since the liver or spleen may be swollen which may cause rupture. Inform the patient that signs and symptoms of infection include fever, chills, sore throat, enlarged lymph nodes, and fatigue. Emphasize the importance of self-care while the disease runs its course, which includes adequate fluid and nutritional intake along with sufficient rest. Patient is encouraged/instructed to use (over the counter) OTC ibuprofen or Tylenol to reduce fever. (Kormos, W. 2014).

CONSULT/REFERRAL: Patient to consult provider if fluctuant fever or new symptoms appear such as nausea, vomiting, abdominal pain, neck stiffness, swollen testicles, skin rash, increased fatigue, cough or shortness of breath. (Rana, R. S., & Moonis, G. 2015).

FOLLOW-UP: In the event of worsening symptoms or onset of new symptoms, patient is advised to seek medical assistance immediately.

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