Chief Complaint: 15 year old, Hispanic male who report sore throat and for 2 days.
History of Present Illness: Per patient report, he was in his usual state of good health until 2 days ago when he started feeling a throbbing throat pain. The pt denies pain in any other part of his body. The sore throat is al most constant and states feeling a throbbing sensation. Aggravating factors are swallowing and talking. The patient feels some short relief when he takes lozenges or eats something cold. Pt states awakening at night due to the throbbing throat pain. Currently, the pain level is 7/10 in a numeric scale (0-10). Denies any other associated symptoms such as headache, fever, chills, drooling, problem swallowing, hoarseness, sneezing, runny
…show more content…
Nutritional History: Patient eats 3 meals a day. Patient eats a lot of fast food during lunchtime, states he does not like school food. Eats breakfast and dinner at home. Likes sodas and energy drinks. States he should drink more water.
Psycho-social/ Spiritual hx: Patient lives with his mother and maternal grandmother. He has no siblings. Have three dogs the loves. The patient report helping his family with house chores. He is currently in the 9th grade and attends a high school. He plays football 3 x a week. He states having a lot of friends and go out to do activities every week. Denies drinking alcohol, smoking, or using illicit drugs. Attends a Christian Church every Saturday and Sundays.
Sexual/reproductive hx: The patient states he has never been sexually active, and denies oral sex engagement.
ROS: Negative for SOB, fever, cough, sputum, rhinorrhea, sneezing, hoarseness, sinus pain, ear pain, conjunctivitis, vision changes, light sensitivity, hearing difficulties, weight loss, fatigue, decreased activity level, headaches, mouth sores, swollen lymph nodes, head trauma, fainting, loss of consciousness, murmurs, irregular heartbeat, malaise, stomach pain, nausea/vomiting, diarrhea, jaundice, petechiae, rashes, and
…show more content…
Plan:
Diagnostic Plan: Laboratory evaluation for Viral Pharyngitis is limited, however, identification for group A b-hemolytic streptococcus infection may be needed in order to treat the patient appropriately. Laboratory include a rapid screening test for streptococcus if the result is negative a throat culture is obtained (Dains, et. al., 2016).
Rx Plan: treatment plan depends of the severity of the symptoms and epidemiologic factors causing pharyngitis. Treatment for viral meningitis may include:
Plenty of oral fluids, salt-water gargling; for soothing effects, and rest (Aung, K. (2016). Lozenges and Tylenol may be taken as needed for pain relief (Aung, K. (2016).
Pt Education/Referral/Follow up Plan: prevention for recurrent infection includes hand washing, avoid contact with infected individuals, isolate utensils, drinking glass from other family members. Wash utensils and personal objects thoroughly with disinfectant soap and water. The patient should notified the care provider if symptoms do not improve in two weeks or unable to swallow, difficulty or noisy breathing, drooling, or high fever > 101 f (Harvard Medical School, 2017).
Health
The only thing can help relieve some symptoms is decompression surgery, which makes room at the back of the skull for the cerebellar tonsils. This can help restore the flow of CSF around the brain.People who have had the surgery,some will have recurring symptoms,but not all the time. This is due to the nerves being damaged by the compression of the tonsils on them for so long. In that case, the only thing that can be done is symptom monitoring. Syringomyelia/Hydromyelia is another story; Most of the time, the syrinx will dissipate on it’s own. In some cases, it will have to be drained to relieve the spinal nerves of the
Tonsillitis can be described as the inflammation of the non-encapsulated lymphoid structures, lingual and palatine tonsils. These lymphoid tissues are part of the immune system and are the first line of defence against pathogens in the oral cavity. The palatine and lingual tonsils are located underneath the stratified squamous epithelial mucosa of the tongue and oropharynx. The tonsils’ response to bacterial or viral infections of the epithelial mucosa, e.g. streptococci and the Epstein-Barr virus (EBV), is inflammation and enlargement of the tonsils and antibody responses, largely IgA. Symptoms of tonsillitis include Sore throat and fever.
Initial diagnosis of Streptococcal pharyngitis is determined by a point system awarding 1 point for each of the following; temperature greater than 38 C, absence of cough, tender anterior cervical lymph nodes, tonsillar swelling, age younger than 15, subtracting a point for age older than 45. If these symptoms are met, a rapid strep test will be performed before antibiotics are given, a precaution taken to prevent super-bugs from developing.
It is important to begin treatment right away. Treatment will usually involve the use of antibiotic medicines. In some cases, your health care provider may begin treatments before the diagnosis is confirmed. If your symptoms are severe, a hospital stay may be needed.
The patient was referred to the Radiologist from his GP, because of ongoing pain and difficulty when swallowing. The patient was 45years old male, consumed alcohol regularly and a heavy smoker.
This is a 36 year old wihte femle who is here complaining of cough, sinus congestion, fever, and gneralized body ache for 4 days. Patient is a resident at Lovelady and reports many ladys are sick at the center. Patient is a smoker with a history of one pack for 20 year hisory. Patient denies use of alcohol or illicit drug use.Patient denies chest pain, N/V/D, but rports SOB and
Physical examination discloses nasal congestion, discharge, nasal mucosal bogginess, mucous in the oropharynx, or a cobblestone look of the oropharyngeal mucosa..12 Since UACS it is very common and may be clinically unclear, it is judicious to utilize a brief trial of empirical action in the approach to diagnosis. Being that UACS is a syndrome lacking a solid description, is best confirmed by a response to therapy. As the optional treatment (older generation antihistaminics) can suppress the cough reflex centrally and peripherally, response to therapy may not necessarily confirm that the diagnosis is
The assessment was conducted on a patient who was forty nine (49) years old bisexual, a white female and single, a Roman Catholic and who didn't have any child. Most importantly, this patient has worked with me for a period of one year from January 2010; therefore I have been seeing her every week for about fifteen minutes. The patient was given to me by one psychiatrist who came across her at event where the housing project was being commissioned to support Veterans. By that time ,the patient was suffering from Anxiety Disorder NOS and Depression NOS.
No known allergies, no sinus, tenderness, no epistaxis, no bleeding gums, patient has partial dentures, one dental carrier noted, tongue is slightly coated, no swelling, lumps or tenderness noted in throat,
Even though a person of any age can be diagnosed with acute pharyngitis, either viral or bacterial, 30% are childhood aged. Proper diagnosis and treatment are crucially important. Many times childhood aged patients will go undiagnosed because medical providers will underline the reason on performing a rapid or culture test. The proper treatment is of high importance allowing for the patient to get better soon and return to normal activities as well as eliminating the spread of germs from on to another. It is highly encouraged to seek medical attention if and when someone is not sure if that person could have a virus or bacterial
Acute tonsillitis is inflammation of the tonsils secondary to an infectious process causing painful swallowing and is more commonly attributed to a viral cause rather than bacterial (Shepherd, 2013). A physical assessment of the tonsils may reveal an increase in size with edema and erythema. This is often associated with upper respiratory symptoms like, headache and cough (Shepherd, 2013). Another diagnosis is pharyngitis. Pharyngitis is also a sore throat which is secondary to inflammation noted at the back of the throat and associated with complaints of pain when swallowing (Shepherd, 2013). Viral pharyngitis is the most common and can be contributed to the rhino or coronavirus which lasts between 5-7 days and presents with associated symptoms like cough, headache, fatigue and mild fever (Ruppert & Fay, 2015). Finally, GABHS or more commonly noted as strep throat is a potential diagnosis. This bacterial infection is most common in children and adolescents. Often individuals present with symptoms including throat pain, fever, chills, headache, cervical lymphadenopathy and exudate noted to tonsils or in the pharyngeal (Ruppert & Fay, 2015). This infectious process in younger children may also present with gastrointestinal symptoms like nausea, vomiting and abdominal pain but is not accompanied by cough or nasal
When infected, the treatments must start as soon as possible. When going to go treatment, a doctor must and will make the decision to treat the infection based on the symptoms. Safe and effective prescription drugs can treat the infection and the symptoms.
Patient T is a newborn weighing 10 pounds, and 4 ounces, and looks like a healthy, strong, and big new baby boy; during his childhood, he maintains normal weight, and lives an active life with a great appetite for food that includes: apples, pears, bananas, ham sandwiches, chips, and pizza. When entering kindergarten, he’s considered as hefty, which leads to him being shy, and antisocial. When he gets home, all he does is: watch TV, play video games, and snack on foods, and drinks consisting of: chips, and 8 cans of soda a day. When he enters high school, he starts playing football with performance’s worthy of entering a Division 1 college. As a result of
Gold standard procedures should be implemented with the aim of providing timely and accurate results. (Schentag) The culture result should be accompanied by its clinical significance, selective reporting of susceptibility testing results in accordance with hospital antimicrobial therapy guidelines and suggested management. (Schentag) This encourages appropriate prescribing and minimises unnecessary use of antimicrobials. The clinical microbiology team should also provide reports to AMS regarding resistant organisms.
pyogenes is GAS (Group A streptococcal) pharyngitis. Individuals of any age can be diagnosed with pharyngitis, however it is the leading bacterial infection within children above the age of 3. Transmission of pharyngitis between individuals is usually by direct contact or droplets. The most common route for this organism to be passed on from one individual to another is through droplet transmission. Aside from these two transmission methods, food borne outbreaks have also been seen in the past. The incubation period is generally around 1-4 days. Common symptoms of pharyngitis that are seen following the incubation period within individuals are sore throats, fever and chills. These symptoms can be seen within exudative forms of pharyngitis as well. Another common symptom is malaise. This is where the individual will feel general discomfort or illness. Symptoms that are particularly seen in children are complaints of abdominal pain and vomiting. Depending on the individual, symptoms can range from mild discomfort to severe sore throats with associated swelling of the pharyngeal mucosa. In addition to these, erythema (redness of skin) is also commonly seen and as well as exudate covering the pharyngeal walls. Exudate coverings are seen alongside sensitive cervical lymph nodes. The symptoms experienced as a result of streptococcal pharyngitis are different from those experienced by individuals with viral