Question

Jim is a 29 year old computer programmer. He presents today c/o feeling badly for 7-10...

Jim is a 29 year old computer programmer. He presents today c/o feeling badly for 7-10 days. He states that he has had fever of 100-103 degrees, sore throat and body aches all over. He denies cough, shortness of breath, dysuria or frequency.

Jim says that he is healthy, with no chronic health problems. He has never had surgery. He takes no routine meds. He does not smoke. He has no known allergies. He drinks alcohol 3-4 times per week, 3-4 glasses of red wine. He says that he has done some street drugs, smoking and injecting cocaine. Jim states that he has given up the cocaine, has not used any in 4-6 weeks. He admits to recreational use for only a 3 month period earlier this year, with the last episode being 4-6 weeks ago.

Jim is single. He and his girlfriend of 4 years broke up about 6 months ago and he has had unprotected intercourse 3 times since then with different partners.

On his physical, Jim is a well-developed white male in no acute distress. His vital signs are: 99.6-84-18   120/66 72” 180#

His skin, hair and nails are normal. He has some cervical lymphadenopathy and his spleen is one finger breadth below the left costal margin. The remainder of his physical is normal.

What are his medical diagnoses?

What are his differential diagnoses, with rule outs?

What diagnostics are needed?

What prescriptions does he need?

What education does he need?

Homework Answers

Answer #1

¤The medical diagnosis is Strep Throat

¤The differential diagnosis can be acute bronchitis ,tonsillitis, pharyngitis ,spleenomegaly

¤The diagnostic which is required ate

  • Throat swab or culture to rule out any growth of microorganisms
  • CBC:to rule out any infection
  • USG abdomen :to assess any enlargement of spleen
  • Fever panel
  • Lymph biopsy

¤The following prescription is required

  • Antipyretics to reduce fever
  • Analgesics to relieve body pain
  • Antibiotics to treat infection

¤The following education is needed

  • Adhere to medication
  • Do not over dose or under dose
  • salt water gargle to relieve sore throat symptoms
  • Follow up as per order
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