Sore Throat

Ella T. is a 19-year-old woman with no past medical history with a complaint of sore throat for the past 3 days. 

History elements: 

Onset: three days ago when she awoke in the morning

Palliative: nothing makes it better 

Quality: sharp pain, worse when she swallows. 

Radiation: does not radiate

Severity: 5/10 

Timing: is constant pain, but worse when she swallows. 

Recent travel: denied recent travel

Sick contacts: her partner has been complaining of fatigue for the past few weeks, and he had a sore throat a few weeks ago.

Pertinent positives: fatigue, subjective fever, loss of appetite, muscle aches and pains

Pertinent negatives: cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, chills, rash, headache  

No past medical history

Sexually active with one male partner, partakes in oral intercourse and penis in vagina intercourse, does not use protection, has been tested for STIs and has never tested positive for any STIs.

Physical exam: 

Vitals: HR 86 BP 120/80 T 100.8 F, RR 18 SPO2 98% 

Head: normocephalic atraumatic 

Eyes: symmetrical OU with no ptosis, lid lag crusting, swelling. EOMIs intact, visual fields full by confrontation, PERLLA, no nystagmus. Conjunctiva pink, sclera white. 

Nose: nares patent bilaterally, no discharge. Frontal and maxillary sinuses nontender to palpation

Ears: no pain on palpation of tragus or helix bilaterally, canals non erythematous non exudative, TMs intact. 

Throat: soft palate petechiae noted, exudative tonsils 1+, normal dentition no obvious signs of caries, no uvular deviation. Mucous membranes moist. 

Neck: tender posterior cervical lymphadenopathy. No thyromegaly. 

Skin: warm, no rashes or lesions noted. 

Chest: lungs clear to auscultation bilaterally, unlabored respirations. Regular rate and rhythm, no murmurs, rubs or gallops S1 and S2 auscultated

Abdominal: splenomegaly noted. Bowel sounds present in all 4 quadrants, tympanic throughout, nontender to palpation. Soft and nondistended. 

Differential diagnosis: 

1. Infectious mononucleosis: sick contact, sore throat, posterior cervical lymphadenopathy, exudative tonsils
2. Streptococcal pharyngitis: sore throat, lack of cough, fever, exudative tonsils
3. Influenza: myalgia, fever, sore throat, fatigue, malaise

Tests: 

1. Rapid strep test: negative (centor criteria is 3: fever, lack of cough, exudative tonsils)
2. Rapid influenza test: negative
3. Monospot test: positive 
4. CBC: lymphocytosis 
5. Blood smear: atypical lymphocytes 

Treatment: 

1. Acetaminophen 650 mg every 4-6 hours  or Motrin 600 mg every 6-8 hours for symptom control as needed
2. Warm saline throat gargles for sore throat as needed

Education: 

1. Drink plenty of fluids, rest and eat nutritiously 
2. Avoid contact/rough sports/activities for at least 4 weeks to avoid splenic rupture since the patient has splenomegaly 

Sources: 

Aronson, M. MD (2021, March 19). Infectious Mononucleosis. Retrieved from https://www.uptodate.com/contents/infectious-mononucleosis?search=infectious%20mononucleosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Herel, J. PA-C (2020).  Acute Cough, Sore Throat, Rhinorrhea. Retrieved from Powerpoint. 

QMDT. Epstein-Barr Virus (EBV) & Infectious Mononucleosis. Retrieved from access medicine