Case Study

CHIEF COMPLAINT: "My throat hurts." History of Present Illness:

Ashley S., a 7-year-old elementary school student, is brought to your office by her mother. She has had a fever and a sore throat for 24 hours. She is normally healthy and has never had any surgery. Other children in her classroom have been sick with similar symptoms. There are no smokers in her household. She has no difficulty swallowing.

On review of systems, you elicit the information that she has had clear nasal drainage and a nonproductive cough. She has not vomited or had diarrhea. Her mother states that Ashley has had a decreased appetite but is drinking liquids.

What parts of the exam would you like to perform? (Circle the appropriate areas.)

General Survey Breasts and Axillae

Vital Signs Female Genitalia

Skin Male Genitalia

Head and Neck Anus, Rectum, and Prostate

Thorax and Lungs Peripheral Vascular/ Extremities

Cardiovascular Musculoskeletal

Abdomen Nervous System

What physical findings are you looking for to help determine the diagnosis?

These are the actual findings on physical examination:

General Survey Alert and interactive child; appears slightly flushed

Vital Signs



Thorax and Lungs



BP 90/60 mm Hg; HR 100 bpm and regular; respiratory rate 20 breaths/min; temperature 103.5°F

No rash

Normocephalic, atraumatic

Pupils equal, round, and reactive to light and accommodation; constrict from 4 mm to 2 mm

External ear canals patent; tympanic membranes pearly gray, with good cone of light

Nasal mucosa pink

Anterior tonsils increased in size with purulent exudates bilaterally; no evidence of obstruction in the posterior pharyngeal wall; gag reflex intact

Supple, with no thyromegaly; anterior cervical nodes are enlarged to 2 cm; no stridor

Thorax symmetric, diameter is appropriate for age

Breath sounds vesicular

PMI nondisplaced

Good S1, S2; no S3 , S4; no murmurs, rubs, or gallops

Soft, with active bowel sounds; nontender, without hepatosplenomegaly or masses

Based on this information, what is your differential diagnosis?

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