Angelika Dabu

Master’s of Science in Physician Assistant Studies

OSCE Case

Case Scenario
  • T.J. is a 16-year-old male with no past medical history who presents with a chief complaint of fever and sore throat x 2 days.


History Elements

  • Symptoms started when he woke up in the morning 2 days ago
  • Last temperature taken this morning was 101.8 degrees Fahrenheit
  • Throat soreness is constant, 6/10, worse with swallowing
    • Has not been eating as much since throat pain started
  • Feeling very fatigued and lethargic with body aches all over, spending most of his time in bed
    • Normally very active and plays basketball with his friends every day after school but has not had the energy
  • Headache also started about 2 days ago, persistent, tension-like
    • Not throbbing or sensitive to light or sound
  • Denies taking any medications or any alleviating or aggravating factors
  • Denies chills or night sweats
  • Denies chest pain, cough, or shortness of breath
  • Denies abdominal pain, nausea, vomiting, diarrhea, or constipation
  • Denies recent tick bites or rash
  • Denies sick contacts or recent travel


Past Medical History: Denies
Past Surgical History: Denies
Immunizations: Up to date
Medications: Denies
Allergies: Seasonal allergies, NKDA
Family History: Non-contributory
Social History: Lives at home with mother, father, sister, and dog. Denies any smokers at home. Attends school in person 5 days a week. Plays basketball with his friends regularly after school.
Sexual History: Currently sexually active with girlfriend, uses barrier protection with condoms. Denies any history of STIs.

Physical Exam
  • Vital signs
    • BP: 108/68
    • HR: 88
    • RR: 16
    • T: 102.0 degrees Fahrenheit 
    • Height: 5’ 6”
    • Weight: 134 lbs
    • BMI: 21.6
  • General: Well-developed, well-nourished, A&Ox3, in no acute distress.
  • Skin: No rashes, pigmentations, petechiae, or infections.
  • Head: Normocephalic and atraumatic. Normal hair texture and distribution.
  • Eyes: PERRLA. EOMs intact. Conjunctiva clear.
  • Ears: Canals clear. Right TM erythematous. Left TM normal pearly gray.
  • Nose: Septum and turbinates within normal limits. No discharge or deformities.
  • Mouth/Throat: Mucous membranes moist. Pharynx erythematous. Tonsils injected with patchy exudates.
  • Neck: Supple. Trachea midline. Thyroid WNL.
  • Nodes: Cervical and tonsillar nodes enlarged and palpable bilaterally.
  • Pulmonary: Lungs clear to auscultation bilaterally. Normal pulmonary effort. No adventitious sounds.
  • Cardiac: Normal S1, S2, RRR. No murmurs, rubs, or gallops.
  • Abdomen: Soft, nondistended, nontender. Bowel sounds normoactive in all 4 quadrants. No guarding or rebound tenderness. Splenomegaly and mild hepatomegaly on palpation.
  • Extremities: FROM. Normal muscle tone and strength.


Differential Diagnosis

  • Infectious mononucleosis
    • Sore throat, fever, fatigue, tonsillar exudates, lymphadenopathy, dysphagia, splenomegaly, hepatomegaly, lymphocytosis
  • Cytomegalovirus
    • Sore throat, fever, fatigue, myalgias, lymphadenopathy, elevated lymphocytes
  • Streptococcal pharyngitis
    • Sore throat, fever, tonsillar exudates, lymphadenopathy, dysphagia
  • Viral pharyngitis
    • Sore throat, fever, lymphadenopathy, dysphagia, myalgias


Tests

  • CBC with differential: Elevated lymphocytes and monocytes, lymphocytosis 
  • Monospot [heterophile antibody test]: Positive 
  • Strep test: Negative
  • CMP: Elevated AST, elevated ALT 
  • Serum EBV IgM and IgG antibodies: Positive 
  • Serum CMV IgM and IgG antibodies: Negative
  • Abdominal ultrasound: hepatosplenomegaly
  • Peripheral blood smear: atypical lymphocytes


Treatment

  • Supportive treatment
    • Antipyretic and analgesic, such as Motrin 600 mg every 6 to 8 hours, or Tylenol 650 mg every 4 to 6 hours, as needed
    • Rest
    • Fluids to maintain hydration
    • Lozenges or throat sprays


Patient Counseling

  • Avoid contact sports for at least 3 to 4 weeks to avoid possible trauma/collision and splenic rupture.
  • Refrain from kissing, intimate contact, sharing drinks, food, sports equipment, or personal items, such as toothbrushes or eating utensils, due to the virus being contagious.
  • Return for repeat CMP in 4 weeks to assess whether liver enzymes are back to baseline.


References

Epstein-Barr Virus (EBV) & Infectious Mononucleosis. In: Papadakis MA, McPhee SJ, Bernstein J. eds. Quick Medical Diagnosis & Treatment 2021. McGraw-Hill; Accessed June 15, 2021. https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?bookid=2986&sectionid=251092555
Nall RW. Infectious Mononucleosis. In: Stern SC, Cifu AS, Altkorn D. eds. Symptom to Diagnosis: An Evidence-Based Guide, 4e. McGraw-Hill; Accessed June 15, 2021. https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?bookid=2715&sectionid=249062005
UpToDate: Infectious Mononucleosis

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