The patient is a 20-year-old white female. She came in to the clinic with complaints of fatigue, sore throat, body aches and a headache. The patient has a medical history of Polycyclic Ovarian Syndrome (PECOS) and she stated that she went through early menopause at the age of 17. The patient also says that she has a weak immune system and gets sick often. Social History The patient informed me that she is currently working at Subway and that she is not in school.
She says that she has not traveled anywhere out of the area recently, UT that she did encounter many people that have been traveling at a New Year’s party she attended. Presentation Upon doing vitals and a preliminary examination on the patient, her blood pressure and pulse were in normal range, but she was running a 102. 1 fever. She appeared flush and her throat was red and swollen. The patient’s auxiliary and right superficial cervical lymph nodes were distended. The patient’s uvula was also enlarged, signaling uvular edema. The physical examination also showed signs of an enlarged spleen.
Hospital Course The clinic ran a complete CB, an Erythrocyte Sedimentation Rate Test (USER) and a hotelier antibody test. Final Diagnosis The CB showed that the patient had minor leukocytes. The USER revealed a high sedimentation rate. Finally, the hotelier antibody test came back positive, affirming the diagnosis of Mononucleosis. Treatment We prescribed the patient ibuprofen for the fever, edema and pain. We also gave a steroid shot to help immediately subdue symptoms. Patient was instructed to get plenty of rest and not to do any strenuous activity.