Reference no: EM134040568
Assignment:
Chief Complaint: Sore throat, fever, and chills.
History of Present Illness: A 26-year-old man with a history of asthma and diabetes presents as a new patient with a 4-day history of a sore throat that had worsened overnight. His throat initially started hurting 4 to 5 days ago; however, he now has associated subjective fever, chills, and pain upon swallowing. The pain is burning, constant, rated 8/10, and it radiates to his left ear. He has been taking ibuprofen the last 4 days without significant relief. The patient has had sore throats prior to this episode, but he has "never had pain like this before." Previous episodes typically occurred with symptoms of a "cold" and lasted 1 to 2 days. He is able to tolerate soft foods and liquids. He is accompanied today by his father.
Review of Systems: positive for fever, chills, odynophagia, trismus, and otalgia. His ROS is negative for malaise, fatigue, nausea, vomiting, cough, SOB, hemoptysis, abdominal pain, neck pain, and rash.
Past Medical History: type 2 diabetes and asthma, both well controlled.
Social History: He is married and has one daughter. He denies tobacco use, drinks "a few" beers on the weekend, smokes marijuana on occasion, and denies other recreational drugs.
Allergies: No known drug allergies; no known food allergies.
Medications:
• Albuterol inhaler two puffs inhaled, q4h to q6h.
• Metformin 500 mg PO BID.
ENT/Mouth: Bilateral TM intact, pearly gray in color, cone of light noted, serous fluid appreciated on the left; no erythema or exudates noted. Mucosa pink and moist; no lesions, swelling, or drainage noted in nose. Difficulty opening his mouth. Buccal mucosa slightly dry, posterior pharynx is erythematous, mild white tonsillar exudate bilateral, (2+) tonsillar enlargement on the right, (3+) tonsillar enlargement on the left, and deviation of the uvula toward the right noted.
CASE QUESTIONS:
1. What are your differential diagnoses?
2. What is the most likely diagnosis? Please provide your rationale
3. Briefly discuss the pathophysiology of the most likely diagnosis.
4. Should tests/imaging studies be ordered? Which ones? Think about tests/imaging beyond the primary care setting as well. Please provide your rationale.
5. What are the next appropriate steps in management? Please include pharmacological and non-pharmacological treatment, education plan and follow-up and disposition.
6. Think about interprofessional collaboration for this case. Provide a list of specialties or other disciplines and indicate what contribution these professionals might make to managing the patient.