Week 6 Case Study 2:

Subjective: Ana is a 17-year-old female who presents to your clinic with symptoms of sore
throat, fever, dysphagia, headache, and nasal discharge for 2 days. The fever varies from 99.2 to
100, but this morning her temperature was 100.6 without chills. This morning also she noticed a
mild dry cough. She took 2 Tylenol regular strength earlier before she came to school and the
fever was gone. She denies exposure to upper respiratory infections, nausea, vomiting, diarrhea,
and neck stiffness. She denies previous and current exposure to sexually transmitted infections.
Level of pain 7/10. PMH: Negative. PSH: Negative. Medications: Tylenol PRN. She has no
known allergies. Last menstrual period September 18th. Patient does not smoke, drink, or use
recreational drugs.

Objective:

Constitutional: Patient is alert x3. She appears well for stated age. Appears in moderate pain and
speaks with a muffled voice. Vital signs: 100.2, 88, 18, 118/68, oxygen saturation 98% on room
air, 150lbs, 5’8”.

Physical: HEENT: Normocephalic and atraumatic. Conjunctivae and EOM are normal. Pupils
equal, round, and reactive to light. Vision: Normal. Nose: Nasal turbinates intact with clear
discharge. Ears: Bilateral ears intact. Cervical lymph nodes tender to touch. Cervical range
of motion within normal limits. Oropharynx: Tonsils red, swollen, with moderate white
patches. Surrounding tissues moderately swollen and tender. No drooling, no soft palate
petechiae, positive halitosis. Cardiovascular: Normal rate and regular rhythm. S1-S2 sounds
audible. No murmurs, no gallops, palpitations, or chest pain. Bilateral pulses present x4
extremities. Respiratory: Respiratory effort and breath sounds are normal. Lungs clear to
auscultation. No SOB, no dyspnea, no wheezing, no rales. Cardiovascular: Spleen size within
normal limits.

Based on subjective and physical assessment answer the following questions:

1. What are the differential diagnosis? Provide ICD codes.

2. What is definitive diagnosis? Provide rationale and ICD codes.
3. What diagnostic tests will you order for this patient? Rationale for ordering the tests.
Provide CPT codes.
4. What is your treatment plan/interventions for this patient? Provide rationale for
your choice(s).
5. Discharge/education

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