1. Case #92: Say Ahhhh! BY AMI ALANIZ

2. Gross Overview Note the: Soft palate: general appearence Tonsil: size and general appearance

3. The Patient

4. Profile  female  11 years old  Caucasion

5. 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

6. Social History  Attends 6 th grade  Plays baseball  Mother and mother’s boyfriend smoke in the house

7. The Symptoms

8. 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.

9. Case Question #2 “What is the single major risk factor for acute streptococcal pharyngitis in this case study?”

10. 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”

11. Case Question #2: Answered Involvement in sports as well as the strep throat going around at her school.

12. Present Illness (cont’d)  appears…  ill  pale  shivering

13. Present Illness (cont’d)  ill for three days  sore throat  temperature of 102.3  chills  pain with swallowing

14. Testing

15. 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

16. 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

17. Tonsilllar edema and erythema with yellow-white exudate

18. Soft Palate Erythema (extreme!)

19. Not a Strawberry Tongue

20. Prominent “Strawberry” Tongue

21. Testing, Testing (cont’d)  Neck  small, mobile anterior lymph nodes (tender to touch)  Skin  warm  pale  no rash

22. Lab Results HB 13.2 g/dLNeutrophils 72%Basophils 1% Hct 43.9%Lymphocytes 21%ESR 18 mm/hr Plt 390,000/mm^3Monocytes 5%CRP 2.3 mg/dL WBC 15,500/mm^3Eosinophils 1%(+) Rapid streptococcal antigen test

23. Case Question #1: Answered  fever  Warm skin  Pale skin  Absence of rash  Tonsillar edema  Tonsillar erythema with yellow-white exudate  soft palate erythema  prominent “strawberry” tongue  white blood cell count  neutrophils  lymphocytes  “strep has been going around school for the past two weeks”  participation in sports (presumably at school)  chills  lack of appetite  tiredness  possible weak immune system  pain with swallowing  tender with palpitation lymph nodes

24. Final Notes

25. 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.”

26. Case Question #3 “What are the drugs of choice for this patient?”  penicillin  cephalorsporins (like cephalexin)  erythromycin-based medications  clindamycin  azithromycin

27. Case Question #4 “For which type of heart disease is this patient at risk if treatment is not started?” Rheumatic fever.

28. 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