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Subjective Data
Kelly is a 24-year-old white female. She addresses a hospital with her chief complaint (a sore throat). She comes here on her own. She looks normal and calm. The only problem is that she does not talk a lot because it is evident that this necessity causes some pain and makes her touch her throat.
Chief Complaint
Sore throat during the last five days:
History of Present Illness (HPI)
One week ago, Kelly was in good health and lived her routine life: went to work, met her friends, and visited her gym. During the last five days, Kelly has suffered from painful swallowing. She observed that pain worsened when she started talking. Besides, two days ago, Kelly noticed her eyes watering without any reason from time to time. However, the problem disappeared in several minutes. Yesterday, she had a headache that had gone after taking medication and two hours of sleep. She believed that that headache began because of her not pleasant communication with a customer. As soon as she forgot about the case, no similar cases were reported.
She also states that when she drinks a cup of warm milk, she feels relief. Still, as soon as she starts talking pain comes back. No cough bothers her. From time to time, she feels that she lacks energy. As a rule, she drinks a cup of tea or a glass of fresh (not cold) juice. Difficulty swallowing does not provide her with an opportunity to drink as much as she wants.
Past Medical History (PMH)
In the past ten years, she had several cases of flu without any complications. She took medications to improve her health. Still, she does not remember the names and does not have any medical records. At the age of eight, she broke her arm. She wore a plaster bandage for two weeks without any complications. At the age of 21, she had a gynecological disorder treated with a medication Kelly does not remember.
No surgeries have been done. No allergies have been observed regarding the medications she had to take. To treat her sore throat, Kelly bought a Chloraseptic sore throat relief spray on her own. It helped to forget about her pain for some time. Still, the pain came back soon. It was difficult to swallow and talk. When she had a headache, she took one pill of Ibuprofen before sleep.
Family History (FH)
Kellys grandparents died in a car accident ten years ago. They did not have any serious health problems. Her parents are alive. The patients father has a long history of hypertension. Her mother had a heart attack ten years ago with no complications. Her 12-year-old brother was diagnosed with chickenpox six months before. All precautionary methods were taken. No cases of cancer or diabetes are observed in the family.
Social History (SH)
Kelly is single (no constant sexual partner). No children. She lives apart from her parents in her apartments. She earns for living on her own. She has already changed her job for two times. Now, she believes that her salary and working conditions are appropriate for her. She has a smoking history of five years (one pack per week). When she has some health problems, she avoids smoking. At this moment, she thinks about quitting smoking for good. She refuses the usage of drugs. Still, she admits that she takes alcohol once per week, but not regularly. As a rule, she meets her friends on Saturday evenings and drinks a glass of wine or beer to support her gang.
Review of Systems (ROS)
Constitutional: no fever, no weight change. HEENT: watery eyes, sore throat, difficulty swallowing, irregular headache. Skin: no rash. Respiratory: no cough or shortness of breath. Cardiovascular: no chest pain. GU: painful intercourses. Psychiatric: episodic lack of energy, no depression, and no anxiety.
Physical Examination
Vital Signs
Blood pressure: 160/80, pulse: 80, respirations: 18, temperature: 98,6, Weight: 60 kg, Height: 165 cm, BMI: 22.
General
On examination, Kelly behaves normally. The only problem is that she does not speak a lot because each word causes pain. HEENT is the system for a physical examination.
Head: normal hear without abnormalities.
Eyes: PERRLA.
Ears: no change in hearing, normal activity, no erythema.
Nose: clean nasal passages, no tenderness.
Mouth and throat: normal lips. White vesicles on the tongue, uvula, and buccal mucosa. The left tonsillar pillar is expanded. The throat color is scarlet.
Neck: moveable with some resistance; tender posterior cervical nodes are slightly enlarged; tender thyroid gland is enlarged (Dains, Baumann, & Scheibel, 2015).
Chest, skin, and lungs are normal, with no pathologies observed. Lungs are clear.
Abdomen: normal bowel sound; no splenomegaly.
Diagnosis
One of the possible diagnoses that may be given to Kelly is acute tonsillitis (ICD-10: J03.90). This disease may be caused by bacteria known as Streptococcus and Actinomyces or some viruses (Bickley & Szilagyi, 2012; Bold, Mateescu, Iliescu, Gaman, & Cernea, 2013). As a rule, this disease is observed among children of the preschool age. However, adults may also be diagnosed with tonsillitis at its different stages because it remains to be one of the common respiratory tract infections with several complications on the heart, brain, and lungs (Furuncuoglu, Saglam, & Kutluhan, 2016).
The main symptoms of tonsillitis are red tonsils, white patches on the tongue or the tonsils, a fever, sore throat, and enlarged lymph nodes. In this case, the patients main complaint is a sore throat. Besides, a physical examination proves that the patient has a high temperature that may be the reason for the lack of energy.
The patient suffered from a headache several days ago. Ibuprofen was taken to relieve pain. Still, it did not help for long. Kelly had difficulty swallowing and speaking. Her extreme weakness and the inability to talk upset her. Finally, in this diagnosis, it is necessary to admit the importance of her smoking history during the last five years. The impacts of tobacco smoking and the environment cannot be neglected in tonsillitis diagnosis (Roberts, Wagler, & Carr, 2017).
Diagnostic Study
A laboratory examination in the form of a throat swab is recommended as one of the possible diagnostic studies (Fischbach & Dunning, 2015). The analysis of a throat culture should help to prove or disprove the chosen diagnosis and identify the main cause of a sore throat. A throat culture is used to detect the presence of GABHS (Group A beta-hemolytic streptococcal infections) that is used as the gold standard of diagnosis (Dains et al., 2015). Nowadays, according to the guidelines, rapid antigen testing is recommended as well (Bold et al., 2013; Bickley & Szilagyi, 2012). It is important not to touch the tongue, but to focus on the throat only to obtain appropriate results and use them for further diagnosis.
References
Bickley, L., & Szilagyi, P.G. (2012). Bates guide to physical examination and history-taking (11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Bold, A., Mateescu, G., Iliescu, G., Gaman, A., & Cernea, D. (2013). Uncommon etiologies of infectious tonsillitis in adults. BMC Infectious Diseases, 13(1), 32-38.
Dains, J.E., Baumann, L.C., & Scheibel, P. (2015). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Health Sciences.
Fischbach, F., & Dunning, M.B. (2015). A manual of laboratory and diagnostic tests (9th ed.). Philadelphia, MA: Lippincott Williams & Wilkins.
Furuncuoglu, Y., Saglam, F., & Kutluhan, A. (2016). Acute exudative tonsillitis in adults: The use of the Centor score and some laboratory tests. Turkish Journal of Medical Sciences, 46(6), 1755-1759.
Roberts, C., Wagler, G., & Carr, M.M. (2017). Environmental tobacco smoke: Public perception of risks of exposing children to second- and third-hand tobacco smoke. Journal of Pediatric Health Care, 31(1), 7-13.
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