Adolescent with Mononucleosis: History and Physical – Sample Solution 1
Adolescent with Mononucleosis: History and Physical
Provider: Patient: J.D.
Date of Service: 20/5/2022 Date of birth: April 23, 2005
Time of Service: 1215 Age: 17 years
Race/Ethnicity: White non-Hispanic Gender: Male
Insurance: United Healthcare PPO
Allergies: NKDA
Medication: Father states the patient has been taking Ibuprofen, Acetaminophen, Pushing Fluids, and Tylenol for aching, pain, and fever.
Chief Complaint: Patient presents with sore throat and fever, which he has had for a week, feeling tired and achy, rash, difficulty swallowing, and abdominal discomfort.
Historian: Father
History of Present Illness: J.D. is a 17-year-old male who presents to the care facility today in his father’s company with a sore throat, fever, fatigue, achiness, rash, difficulty swallowing, and abdominal discomfort complaints. Father states that J.D. began complaining of sore throat, fever, headache, and abdominal discomfort one week ago. The rash began three days ago. Father reports fevers have been approximately 101.4F.
He has been giving J.D. Ibuprofen, Acetaminophen, Tylenol, and Pushing Fluids. Sore throat has remained constant for one week, and he rates it 3 out of 5 on the FACES pain scale. Father reports no information of any known sick contact. The patient admits that one of his friends from the softball team had a sore throat about two weeks ago for several days.
Past Medical History (PMH):
Allergies: NKDA
Current Medications: Father states the patient has been taking Ibuprofen, Acetaminophen, Pushing Fluids, and Tylenol
Age/Health Status: 17 years/ No chronic health problems
Appropriate Immunization Status: Up to date on all vaccines; Father states the patient received a flu vaccine every year as a child. The last flu vaccine was on June 18, 2017. This fall, the patient will receive another at their primary physician’s office.
Childhood Illnesses: Strep throat, ear infection
Dates of Illness during Childhood: N/A
Injuries: No significant injuries requiring hospitalization or medication intervention.
Hospitalizations: No hospitalizations
Surgeries: Tympanostomy tube, 2009
Health Maintenance and Health Promotion:
- Father states good compliance with annual check-ups with the pediatrician and has an appointment for September 21
- Dental visit at least once a year; brushes at least once a day. Cavities were found at the last appointment on the left lower molar in October 2021. Encouraged to continue annual visits to the orthodontist.
- The patient states frequent handwashing
- Well balanced diet
- Father states that J.D. has a pediatrician he regularly sees for immunizations. No immunizations are required at this time.
- Father reports no known lead exposure risks
- Father states the patient is very active, physical activity for most of the day. The patient likes to play with balls, particularly softball, swim and ride bicycles and skateboards. The patient watches T.V. and plays video games daily.
- Patient states he wears a safety belt and sits appropriately in the car. He takes caution during swimming and wears a helmet when riding the bicycle or skateboard. Father has a pistol, which is kept in a locked cabinet, and the patient cannot access the keys. All medications are locked away and kept labeled to avoid wrong medication.
Family History (F.H.): J.D. is the firstborn child in the family. Father is 47 years old, and the mother is 44 years old. Sister is ten years old with no significant medical history. The father states mother has a history of hyperlipidemia and gout. Father has diabetes and is allergic to PCN. Maternal grandmother died when she was 80 years old after suffering from diabetes, stroke, and high blood pressure in her 60s and 70s.
Maternal grandfather is 81 years old and has high blood pressure, and was recently diagnosed with cancer of the colon. Paternal grandmother is 79 years old with a medical history of osteoporosis, obesity, and kidney stones. Paternal grandfather is 79 years old and suffers from type II diabetes. Maternal uncle (age 40) has no significant past medical history. Paternal aunt (age 42) has a medical history of hypertension and arthritis.
Social History: J.D. is in grade 12 this school year. He is active and plays softball in school, and likes riding bicycles or skateboarding after school and during the weekends at the public park. Father states that both parents do not smoke, but the father drinks occasionally.
The patient takes limited daily caffeinated foods and drinks. He is allowed to watch T.V. and play video games daily. Father reports that the patient has had a low appetite after the onset of a sore throat. He went to school using a bicycle, but he did not go to softball practice for the last three days.
Growth and Development:
Physical Growth: Height and weight are appropriate with growth curves per CDC Guidelines (See Appendix B). The patient’s BMI is 23.3, within the healthy BMI range for this patient’s age group.
Motor: Fine and gross motor skills are WNL for the patient’s age.
Cognitive: The patient’s cognitive function is WNL for the patient’s age.
Verbal: Patient with regular communication for age.
Social: Patient’s social development is within normal parameters for his age.
Personality: Patient is intense, agreeable, extrovert, active, but easily distracted and seems uninterested at some times.
School: Patient is in grade 12 this school year.
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Review of Symptoms:
Constitutional symptoms: Father reports sore throat, fever, fatigue, achiness, energy loss, difficulty swallowing, and decreased appetite. Father reports malaise and night sweats. Denies unexplained weight loss or weight gain.
HEENT:
Head: Father reports complaints of mild headache. Denies dizziness or lightheadedness.
Eyes: Denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma, peripheral visual changes, and dry eyes. No corrective lenses. Father states the date of the last eye exam was in September 2019, and exam results were reported normal (20/20 vision).
Ears, Nose, Mouth, and Throat: Father reports sore throat and difficulty swallowing. Denies hearing changes, earache, ear pressure, or tinnitus. Denies hoarseness, vertigo, sinus problems, epistaxis, dental problems, oral lesions, and nasal congestion. The date of the last dental visit was October 2021.
Cardiovascular: Denies any history of a heart murmur, chest pain, palpitations, dyspnea, activity intolerance, varicose veins, or edema. Father states the patient is very active and likes to play softball and ride bicycles or skateboards after school. He participates in physical activity for the majority of the day.
Respiratory: Father denies cough. Denies history of respiratory infections, SOB, wheezing, difficulty breathing, exposure to secondary smoke, T.B., hemoptysis.
Gastrointestinal: Father reports the patient is struggling to eat and seems to have a decreased appetite since the onset of symptoms. Patient admits experiencing pain when swallowing; dysphagia. Denies reflux, pyrosis, bloating, nausea, vomiting, diarrhea, constipation, hematemesis, abdominal or epigastric pain, hematochezia, change in bowel habits, food intolerance, flatulence, hemorrhoids. Father states they try to prepare healthy, well-balanced meals.
Genitourinary: Father denies urgency, frequency, dysuria, suprapubic pain, nocturia, incontinence, hematuria, and history of stones.
Musculoskeletal: The patient denies joint pain and tenderness.The patient denies back pain, muscle pain or cramps, neck pain or stiffness, and changes in ROM. Father states the patient is active for most of the day each day. He wears his seatbelt.
Integumentary: The patient denies itching, urticaria, hives, nail deformities, hair loss, moles, open areas, or bruising. Father reports a rash that began three days ago. The patient and the Father state they apply sunscreen while outside and inspect his skin always for any changes.
Neurologic: Father reports complaints of headache. Denies weakness, numbness, tingling, memory difficulties, involuntary movements or tremors, syncope, stroke, seizures, or paresthesia.
Psychiatric: Father reports mood changes and distress. Denies nervousness, nightmares, anxiety, depression, insomnia, suicidal thoughts, exposure to violence, or excessive anger.
Endocrine: Father denies cold or heats intolerance, polydipsia, polyphagia, polyuria, hair or nail texture, unexplained weight change, changes in facial or body hair, changes in hat or glove size, and use of hormonal therapy. Reports rash on the skin that began three days ago.
Hematologic/lymphatic: Father denies unusual bleeding or bruising. Reports lymph enlargement or tenderness and fatigue. Denies history of anemia and blood transfusions.
Allergic/immunologic: Father denies seasonal allergies, allergy testing, exposure to blood or body fluids, use of steroids, or immunosuppression in self or family.
Developmental: Denies delay of gross or fine motor skills or cognitive development.
Physical Exam:
Weight: 63 kg
Height: 164.5 cm
BMI: 23.3
Vital Signs: Temperature 100.1; BP-118/80; HR 90/min; RR 18/min; O2 sat-99%
General Appearance: healthy-appearing, well-nourished, and a well-developed 17-year-old White non-Hispanic male. Appears moody, tired, and sick but with no acute distress or feelings of anxiety.
Level of Distress: NAD.
Ambulation: ambulating normally.
Head: Nomocephalic/atraumatic. Symmetric. Normal hair distribution and pattern.
Eyes: Sclera white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally. No redness or drainage was observed. Extraocular movements are intact.
Ears: External appearance normal, external auditory canals clear, no lesions, redness, or swelling; on otoscope exam, tympanic membranes clear, no redness, fluid, or bulging identified. Hearing is intact.
Nose: The nose’s appearance is typical, with no mucous, inflammation, or lesions. Nares patent. The septum is midline.
Mouth: Pink, moist mucous membranes. No masses, tongue midline. No missing or decayed teeth.
Throat: Erythema noted, red-based white ulceration to right tonsillar column and soft palate. No exudate. No halitosis. Signs of enlarged thyroid were noted on palpation. Tonsils 2+. Uvula midline and beefy red.
Cardiovascular: S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs. Carotid Arteries: regular pulses bilaterally, no bruits present Pedal Pulses: 2+ bilaterally.
Extremities: no cyanosis, clubbing, or edema, less than 2-second refill noted. Patient is warm and dry, with no edema or cyanosis noted.
Pulmonary/Thorax: Even and unlabored. Clear to auscultation bilaterally with no wheezes, rales, or rhonchi. Breath sounds are clear throughout all lung fields.
Gastrointestinal: abdomen soft and non-tender to palpation, non-distended. No rigidity or guarding, no masses present, and bowel sound present in all four quadrants.
Genitourinary: No bladder distention, suprapubic pain, or CVA tenderness.
Musculoskeletal: Joint stability is expected in all extremities. Patient movements are symmetrical. No weakness was noted.
Integument/Lymphatic:
Inspection: No scaling or breaks on skin, face, neck, or arms. Rash noted on the skin
General palpation: no skin or subcutaneous tissue masses present, no tenderness, skin turgor normal
Face: rash noted, no lesion, or discoloration present
Lower Extremities: rash noted, no lesion, or discoloration present
Upper Extremities: rash noted, no lesion, or discoloration present
Neurologic: Patient is alert and oriented x4, communication ability within normal limits. Patient is easily distracted. Sensation intact to light touch, gait within normal limits
Psychiatric: Judgment and insight intact, rate of thoughts average and logical. Pleasant, calm, and cooperative. The patient appears distressed and uneasy.
Hematologic/immunologic: Swollen and tender anterior cervical lymph nodes, no masses present, no bruising
Back: Spine is WNL with no curvature, deformities, or lesions.
Stages of Development:
Erickson’s Stage of Psychosocial Development: Identity vs. Role Confusion
The patient demonstrates appropriate behavior for this stage of development as he demonstrates a sense of personal identity, which influences behavior. Patient demonstrates a high level of independence by answering some assessment questions that need knowledge at the individual level. He is also uncomfortable when the father answers most of the assessment questions, seeking control over the process.
Piaget’s Stage of Cognitive Development: Formal operational stage
The patient exhibits behavior appropriate for this stage of development because he demonstrates increased logic, ability to utilize deductive reasoning, and comprehension of abstract ideas. The patient can provide solutions to problems and think more logically and scientifically about the world around him. The patient is a good communicator, and the conversations are meaningful. The patient can see and analyze multiple perspectives on a specific situation.
Motor Sensory Development: WNL; Patient can ambulate without assistance. Reports no muscle weakness.
Developmental: The patient’s development is appropriate for his chronological age.
Lab/Diagnostic test/EKG: Rapid Strep Test: negative
Blood test:
Antibody tests: Monospot test confirmed antibodies for the Epstein-Barr virus
White blood cell count: Indicated elevated levels of lymphocytes and abnormal-looking lymphocytes.
Assessment:
- 17-year-old male patient with no significant medical history, normal growth and development, presenting with a sore throat, difficulty swallowing, fever, fatigue, achiness, and abdominal discomfort.
Presumptive Diagnosis
- Mononucleosis- B27.9
- Strep Pharyngitis- J02.0
- Cytomegalovirus- B25.9
- Herpes Virus Type 6- B10. 81
- Tonsillitis- J03. 90
Differential Diagnoses
- Strep Pharyngitis- J02.0
Patients with strep can experience an abrupt onset of fever and sore throat after exposure to someone with strep within the previous two weeks (Ashurst & Edgerley-Gibb, 2018). Patients experience sore throat, difficulty/painful swallowing, fever, headache, enlarged tonsils, tonsillar exudates, pharyngeal erythema, and anterior cervical lymphadenopathy.
Refuting data: Negative rapid strep test, positive monospot test for EBV
- Tonsillitis- J03. 90
Tonsillitis results predominantly from a viral or bacterial infection, and patients develop a sore throat (Anderson & Paterek, 2021). Most patients present with fever, tonsillar exudates, sore throat, and tender anterior cervical chain lymphadenopathy.
Refuting data:
Refuting data: Positive monospot test for EBV
- Cytomegalovirus (CMV)- B25.9
CMV is a widespread virus with manifestations ranging from asymptomatic to extreme end-organ dysfunction in immunocompromised individuals with congenital CMV disease (Gupta & Shorman, 2017). Some symptoms are similar to mononucleosis, including high-temperature aching, tiredness, skin rash, feeling sick, sore throat, and swollen glands.
Refuting data: Positive monospot test for EBV
- Herpes Virus Type 6- B10. 81
HHV–6 leads to a more severe infection in immunocompromised individuals. It primarily targets the nervous system (King & Al Khalili, 2020). Patients present with fever, diarrhea, rash, headache, fatigue, weakness, confusion, seizures, and muscle and joint pains. Some conditions like colitis, encephalitis, and endocrine disorders are related to HHV-6.
Refuting data: Positive monospot test for EBV
Confirmed Diagnosis: Mononucleosis (B27.9); Given the mechanism, mononucleosis was confirmed. The diagnosis was made using the patient’s medical history and reported symptoms, including fever, sore throat, achiness, fatigue, difficulty swallowing, and a rapid strep test that gave negative results. The physical exam indicated erythema, red-based white ulceration to the right tonsillar column and soft palate, and signs of enlarged thyroid noted on palpation. A monospot test confirmed the patient was positive for EBV, which causes mononucleosis. Advised caregiver to follow up with primary care provider as needed. Return to the clinic urgently if new or worsening symptoms develop.
Plan:
- Discharge from hospital
- Medication
- Ibuprofen oral tablet 600mg
Brand name/generic: Advil
Indication: Mild to moderate pain and fever reduction (Ngo & Bajaj, 2021).
MOA: Ibuprofen is a non-selective inhibitor of an enzyme known as cyclooxygenase (COX) that is needed to synthesize prostaglandins through the arachidonic acid pathway.
Dose: Oral tablet 600mg per dose P.O. q4-6hr
Prices: 30 tablets of 600 mg cost around $13.39. A supply of 4 tablets can cost around $10 depending on the pharmacy visited.
- Tylenol for pain and fever
Generic name: acetaminophen
Brand names: Tylenol Ext, Little Fevers Children’s Fever/Pain Reliever, Little Fevers Infant Fever/Pain Reliever
Indication: Temporarily relieves minor aches and pains due to headache, backache, the common cold, minor pain of arthritis, toothache, premenstrual and menstrual cramps, and muscular aches, and temporarily reduces fever (Gerriets et al., 2021).
MOA: Tylenol belongs to a class of drugs called analgesics (pain relievers) and antipyretics (fever reducers). MOA is not well known, but it may minimize the production of prostaglandins in the brain (Gerriets et al., 2021). Prostaglandins are chemicals that lead to inflammation and swelling.
Dose: 12.5 ml every 4 hours or five doses in 24 hours
Prices: The lowest price is around $1.35
The average retail price is $4.02
Contradictions: Tylenol contradictions include hypersensitivity to acetaminophen, severe hepatic impairment, and severe active hepatic disease
- Non-medical remedy: plenty of fluids and rest, saltwater gargles or throat lozenges to soothe the throat
- Follow-up if pain persists in 3-4 days with the primary care provider
- Informed to return to the clinic if the patient develops new or worsening symptoms.
- Monitoring for desired clinical effects and pain relief
Billing Codes:
ICD Codes:
- Mononucleosis- B27.9
- Strep Pharyngitis- J02.0
- Cytomegalovirus- B25.9
- Herpes Virus Type 6- B10. 81
- Tonsillitis- J03. 90
Education:
- Get plenty of rest and fluids.
- Avoid participation in any contact sports for 3-4 weeks
- Complete the entire course of medication prescribed even if the patient feels well
- Encourage hygiene, including regular and good handwashing, toothbrush change to prevent reinfection, and avoid sharing utensils.
- Call the office if the pain returns or becomes more severe, or the patient still indicates difficulties swallowing.
- Monitor and report reactions like hypersensitivity reactions, nausea, rash, or vomiting.
- Monitor return to regular activity and play, and the patient may return to school when afebrile.
No need for further lab tests at the moment.
Referrals depend on if there are any further complications, including the rupture of the spleen, encephalitis, myocarditis, and pericarditis. If these complications occur, the patient can be referred to a hematologist, cardiologists, neurologists, or surgeon.
Evidence-Based Rationale
Infectious mononucleosis is primarily caused by the Epstein-Barr virus (EBV). EBV describes a herpes virus that spreads by contact, mainly through salivary secretions. High levels of oral shedding can persist for a median of 6 months after the onset of the illness. The transition of the virus is typically person-to-person (Mohseni et al., 2020). EBV is a highly contagious disease. Other mononucleosis causes include CMV, Adenovirus, HIV, hepatitis A, and Rubella. About 95% of adults worldwide are eventually seropositive to EBV. The virus is widely disseminated in all population groups but primarily affects young adults 15-24 years old (Mohseni et al., 2020). The disease presents with fever, lymphadenopathy, tonsillar pharyngitis, sore throat, fatigue, feeling sick, and achiness.
References
Anderson, J., & Paterek, E. (2021). Tonsillitis. In StatPearls [Internet]. StatPearls Publishing.
Ashurst, J. V., & Edgerley-Gibb, L. (2018). Streptococcal pharyngitis. In StatPearls [Internet]. StatPearls Publishing.
Gupta, M., & Shorman, M. (2017). Cytomegalovirus. In StatPearls [Internet]. StatPearls Publishing.
King, O., & Al Khalili, Y. (2020). Herpes virus type 6. In StatPearls [Internet]. StatPearls Publishing.
Mohseni, M., Boniface, M. P., Graham, C., & Doerr, C. (2020). Mononucleosis (Nursing). In StatPearls [Internet]. StatPearls Publishing.
Ngo, V. T. H., & Bajaj, T. (2021). Ibuprofen. In StatPearls [Internet]. StatPearls Publishing.
Appendix A
J.D. Family Medical History Genogram
Appendix B
J.D. Growth Chart
https://www.cdc.gov/growthcharts/data/set1clinical/cj41l021.pdf
Appendix C
J.D. BMI Calculation
https://www.cdc.gov/healthyweight/bmi/calculator.html
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