Primary Care:

Case Study
Given Case Scenario:
A 29-year-old African American woman presents with complaints of a sore throat,
nasal congestion, joint pain and fever of 101for the past 2 to 3 days. She has a
toddler and is a stay-at-home mom. At present, the toddler is asymptomatic. The
patient is in overall good health with no underlying problems other than occasional
heartburn for which she takes Mylanta and seasonal allergies for which she takes
OTC Claritin when needed.

CC: “I am exhausted, and this sore throat is not getting any better and my body
aches all over. I don’t want my little girl to catch this from me. I need antibiotics.”

Physical exam:
General appearance: well-groomed, well-hydrated, mildly ill appearing
Blood pressure, 110/70, pulse rate, 104 beats/min and regular; respiration rate,
20/min; temperature, 100.2°F
5΄5΄΄, 125 lbs.
Skin: warm, pale and dry
ENT: TMs, external canal (-) erythema or discharge, Sinuses nontender, (+) clear
rhinorrhea
+ posterior pharyngeal erythema and swelling, (-) exudate
Lungs: clear to auscultation, (-) adventitious sounds, (-) wheezing,
Lymph nodes: (-) posterior cervical lymphadenopathy, (+) anterior cervical
lymphadenopathy
1. What addition subjective data would you elicit from the patient?
2. What addition objective data is needed to make your diagnosis?
3. What diagnostic tests would be indicated?
4. What is your differential diagnosis and the most likely diagnosis?
5. What treatments would you use to manage this patient?

Subjective Data:
29 year old African American woman presents with complaints of sore throat, nasal
congestion, joint pain, fever 101 for past 2 to 3 days. Body aches,
Objective Data:
Vital signs: temp: 100.2 F. BP. 110/70, HR 104, RR:20, Height : 5’ 5”, weight: 125 lbs.
Skin: warm, pale and dry
ENT: TMs, external canal (-) erythema or discharge, Sinuses nontender, (+) clear
rhinorrhea
+ posterior pharyngeal erythema and swelling, (-) exudate
Lungs: clear to auscultation, (-) adventitious sounds, (-) wheezing,
Lymph nodes: (-) posterior cervical lymphadenopathy, (+) anterior cervical
lymphadenopathy
 6. What can you recommend to reduce the risk of recurrence of this
problem?
ANSWER:
1. What addition subjective data would you elicit from the patient?

I would ask frequency of onset, like is this the first time she had these symptoms, or she
had it before recently to identify the reoccurrence, as the patient mentioned “she is tired
of it” ask for any throat pain. Ask for any chills associated with fever, and onset of fever,
like weather is come as sudden onset, or increased temp gradually. Also need to know
patient smoking history and sexual habits, type of housing, and no of people live in
house. Need to ask the characteristics of joint pain, and onset of joint pain in relation to
sore throat. Need to ask for any cough, and mucous production. Ask for any voice
changes with sore throat.
2. What addition objective data is needed to make your diagnosis?

1. Ay conjunctival irritation, mucosal exudates in pharynx area, tonsils. Any

other mucosal ulcers in mouth. Look for characteristic white yellow
exudate. Draining anterior cervical lymph nodes. Look for any
submandibular lymph nodes enlargement. And observe for joint
inflammation symptems Observe for voice change, Spleen enlargement
What Diagnostic test Would be indicated?
Step 1: if it’s the flu season, rapid flu testing needed.
Rapid strep test is also indicated.
Throat swab cultures to identify any step infection if mucosal exudate noted in pharynx,
or tonsillar area, and rapid strep test comes negative.

Subjective:

HPI:
Presents with complaints of a sore throat, nasal congestion, joint pain and fever of 101for
the past 2 to 3 days. Feels exhausted.
PMH: Occasional Heart burn, uses Mylanta, and Seasonal allergies uses OTC

claritin.

PSH: None mentioned.

Family history: have a female Child of toddler age

Social history: Stay at home mom.

Medications: Claritin OTC for seasonal allrgis as needed, Mylanta as needed for

occasional Heart burn

Allergies: NKDA, seasonal allergies.

Immunizations: Up to date (assuming per the given data, need to confirm with patient)

ROS:

General: (+) fever, (-) chills, (+) fatigue, (-) night sweats, (-) weakness, (-)
unintentional weight loss, (-) loss of appetite, (+) pain

Skin: (-) rashes, (-) itching, (-) pigment changes, (-) eruptions (-) burning, (-) lesions

Lymph Nodes: (-) tenderness, (+) anterior cervical Lymphadenopathy, (-) posterior
cervical lymphadenopathy.

HEENT: (-) headache, (-) dizziness, (-) LOC, (-) head injuries, (-) visual changes, (-)
double vision, (-) blurring, (-) glasses, (-) eye trauma, (-) redness on conjunctiva. (-) peri-
orbital edema, (-) eye itching,(-) watery eye (-) light sensitivity (-) hearing loss, (-) ear
pain, (-) discharge, (-) vertigo, (-) tinnitus, (+) nasal congestion, (+) Clear rhinorrhea, (-)
nosebleeds, (-) post nasal drip, (-) sinus pain, (-) hoarseness, (+) sore throat, (-) bleeding
gums, (-) ulcers,(-) tooth pain, (+) posterior pharyngeal erythema and swelling.

Respiratory: (-) cough, (-) sputum, (-) bilateral wheezing,(-) SOB, (-) DOE, (-) orthopnea,
(-) PND, (-) tachypnea, (-) use of accessory muscles.(-) night sweats, (-) exposure to TB,

Cardiac: (-) chest pain, (-) chest tightness, (-) palpitations, (-) edema, (-) claudication, (+)
tachycardia, (-) cyanosis

GI: (-) abdominal pain, (-) tenderness in epigastrium, (+) heartburn, (-) vomiting, (-)
nausea, (-) constipation, (-) diarrhea, (-) loss of appetite, (-) black stools

GU: (-) polyuria, (-) burning, (-) incontinence, (-) CVA tenderness

Endocrine: (-) heat/cold intolerance, (-) weight changes, (-) polydipsia, (-) polyuria, (-)
hair changes, (-) changes in shoe, glove, or hat size

Musculo-Skeletal: (+) joint pain, (-) joint heat, (-) joint swelling, (-) myalgia, (-)
arthralgia, (-) limitations to ROM

Neurological: (-) fainting, (-) seizures, (-) LOC, (-) loss of coordination, (-) changes in
sensation, (-) tremors, (-) weakness,
Objective:

V/S: T=100.2 F BP=110/70 HR= 104BPM, RR=20/min, Ht: 65 inches Wt: 125 lbs

(BMI= 20.8)

ROS:

General: AAOx3, mildly ill appearing 29 year old woman,, well groomed and dressed

appropriately for age. Speech is clear and answers questions appropriately with good eye

contact. No apparent respiratory distress, No epigastric tenderness, mentioned about

ocasional heart burn.

Skin: pale, warm, dry, intact, (-) lesions

Hair: coarse, normal distribution (-) thinning of scalp hair; (-) decreased hair distribution
of arms and lower extremities; (-) unusual facial growth;
Nails: opaque, groomed, (-) ridging, (-) splitting, nail beds pink, (-) clubbing
Head: normocephalic, symmetrical features, (-) edema, (-) tenderness

Eyes: PEARLA bilaterally. EOM (CN III, IV, VI) intact. (-) nystagmus noted. (-)
strabismus noted. Visual acuity intact 20/20. (-) conjunctivitis,
Ears: (-) deformities, lesions or discharge noted. (-) tenderness, swelling, or redness to
Pinna or Canal. Tympanic membrane intact, pearly gray in color, (-) perforation or
discharge noted.
Nose/Throat: Nasal mucosa is pink and moist, (-) deviated septum, (-) tenderness noted
to frontal and maxillary sinuses on palpation., (-) post nasal drip with clear secretions, (+)
clear rhinorrhea
CVS: (+) tachycardia,. (-) chest tightness, (-) chest pain, (-) cyanosis, Normal S1 and S2.
(-) murmur, heaves, lifts, rubs, thrills or gallops noted.
Resp. Chest expnasion symmetrical, Respiratory rate regular, breath sounds clear all
fields, (-) cough, (-) sputum (-) adventitious sounds, (-) use of accessories accessory
muscles
GI: (-) epigastric tenderness, (+) heartburn, (-) black stools, (-) diarrhea, (-) constipation,
(-) nausea, (-) vomiting, (-) abdominal mass, (-) guarding, (-) rebound tenderness, (+)
normoactive bowel sounds in all 4 quadrants; (-) masses, (-) organomegaly
GU: (-) burning, (-) CVA tenderness
Musculoskeletal: (-) kyphosis of spine noted. Full ROM to extremities. Extremities are
equal in size, symmetry, muscle mass and tone. (-) redness, warmth, tenderness, creptius
(+) joint pain
Neurological: CN I-XII grossly intact, (-) Romberg test, (-) involuntary movements or
paralysis; (-) focal weakness/paresis; intact reflexes, Intact cerebral function ,intact
cerebellar function (rapid alternating movement, thumb to finger), intact sensory function
(sterognosis,graphesthesia, 2 point discrimination).
Hematopoetic: (+) fatigue, ( -)easy bruising
Mental Health: (-) anxiety, (-) depression
Assessment:

Based on assessment findings it appears patient has pharyngitis (

Diagnosis: Pharingitis

Rationale for diagnosis:

When trying to differentiate GABHS from other causes of pharyngitis, focus on the
following areas: 1) measured or subjective fever, 2) absence of cough, 3) tonsillar or
pharyngeal exudates, 4) cervical adenopathy, and 5) tonsillar enlargement. Centor Criteria
helps in diagnosing Pharyngitis, which is approved by American college of physicians
and CDC and AAFP guidelines, is mentioned in Figure 1. Based on that criteria, the
patient score is 3. Which gives recommendation to perform a throat culture to rule out
Group A beta hemolytic streptococcal infections.
Figure 1.

Modified Centor score and management options using clinical decision rule. Other factors
should be considered (e.g., a score of 1, but recent family contact with documented
streptococcal infection). (GABHS = group A beta-hemolytic streptococcus; RADT = rapid
antigen detection testing.)

Differential Diagnoses:

Infectious:
Viral Pharyngitis- Adenovirus, influenza virus, parainfluenza virus, RSV
Group A streptococcus -
Epstien barr virus- usually presented with Spleen enlargement.

Non Infectious:
Gastroesophageal Reflux Disease
Postnasal Drip (allergic rhinitis or other respiratory illness)

Plan:
1. Diagnostic Tests
Rapid flu test in flu season.
Rapid Strep test to guide antibiotic therapy (Rapid Antigen Detection Testing)
Throat culture if rapid strep test and flu comes negative.
Gram stain and CBC if any infectious signs noted in pharynx or tonsillar area.
Gram stain of nasal secretions to rule out allergic pharyngitis.

Treatment: Source:
Viral pharyngitis need symptomatic management, antibiotics are never indicated.
Antivirals based on the severity and time of onset like if the onset is less than 48 Hrs,
oseltamivir 75 mg PO BID for 5 days is recommended.

A. Pharmacologic
Adults are typically given a 10-day course of penicillin V potassium (Pen-Vee K; 500
mg PO 2 times daily or 250 mg PO 4 times daily) or benzathine penicillin (Bicillin;
1.2 million units IM once) as an alternative to prolonged oral medication. If the
patient is allergic to penicillin, erythromycin (250 mg PO daily) is recommended. If
the patient fails to respond to antibiotic therapy, tests for infectious mononucleosis
and streptococcal antibiotic sensitivity should be performed. A 10-day course of
amoxicillin/clavulanate (Augmentin; 40 mg/kg PO daily based on the amoxicillin
component in devided doses 2 times daily), erythromycin ethyl succinate (50 mg/kg
PO daily in divided doses 3 times daily), or erythromycin stearate (1 g PO daily) have
all been shown to be effective for penicillin-resistant betalactamase–producing
organisms, whereas tetracycline or trimethoprim-sulfamethoxazole preparations
(Septra, Bactrim) should be avoided.
N gonorrhoeaeinfection calls for ceftriaxone (Rocephin; 125 mg IM once), along with
empiric treatment for C trachomatis (azithromycin [Zithromax] 1 g PO once or
doxycycline 100 mg PO 2 times daily for 7 days), given its propensity for co-
infection. Extensive throat infection with Candida albicans (thrush, pharyngitis,
esophagitis) requires antifungal treatment such as fluconazole 200 mg PO daily once,
followed by 100 mg PO daily for 2 weeks total. M pneumoniae and C pneumoniae
are both treated with erythromycin 250 to 500 mg PO 4 times daily for 10 days,
depending on the specific preparation.

B. Non-Pharmacologic
If the patient has fever rest is indicated, along with appropriate hydration. (usually at least
8-12 glass of water, or non-acidic juices. Regular physical activity should be resumed
only after 2 to 3 days of normal temperature readings. Salt water gargling, and hot/cold
double strength tea helps in releaving the sore throat. Voice rest, and appropriate
humification helps in relieving dryness in throat. Over the counter nonprescription
lozenges help in soothing the throat. Warm moist compress helps in relieving cervical
lymph node enlargement and tenderness if any.

Education:
prevented by avoiding contact with persons with actively inflamed throats, particularly
with URIs. Throat swabs from household members of patients should also be cultured to
identify and treat carriers simultaneously in an effort to prevent the development of
clinical disease and prevent reinfection. Toothbrushes should be replaced as soon as a
sore throat develops because they may harbor causative microorganisms, and all eating
and drinking utensils should be cleaned thoroughly and should not be shared. Food and
washcloths also must not be shared during a period of active infection. It is critical to
keep all immunizations up to date, particularly the diphtheriapertussis-tetanus (DTaP,
Tdap) vaccine that confers immunity against C diphtheriae.
, patients must be cautioned not to burn the skin inadvertently. Although the use of aspirin
during viral infections in adults has not been linked to the development of Reye’s
syndrome (as is the case in children), NSAIDs should be used cautiously if patients suffer
from ulcers or other
Patients must be instructed to finish their entire course of antibiotics or antifungals to
avoid complications from latent infection such as glomerulonephritis or myocarditis.
In cases involving dysphagia, patients may be instructed on how to maintain a healthy
liquid or soft food diet (e.g., milkshakes, soups, and high-protein diet or instant breakfast
drinks) for a few days until the pain subsides.
Follow –Up:
If symptoms fail to improve within this time, patients should return for a follow-up
appointment. Throat cultures for Streptococcusmay be repeated on completion of therapy
to confirm resolution of any infectious processes. Identify the risk for rheumatic sequale,
and monomucleosis infections etc.
Referral:
All patients developing suppurative or retropharyngeal sequelae should be referred
to an otolaryngologist. The physical exam and treatment of C diphtheriaeinfection is
also highly risky and must be supervised by a qualified specialist. Surgical
interventions such as tonsillectomy or abscess drainage require surgical referral

Reference:

ICD9 Data.com. 2013 ICD 9 code for IBS. Retrieved from:

http://www.icd9data.com/2013/Volume1/520-579/560-569/564/564.1.htm

Malone, K.L., Fletcher, K.R. & Martin-Plank, L. (2014). Advanced Practice Nursing in
the Care of Older Adults. Philadelphia, PA: F.A. Davis Company.