CC: Sore throat

1
CC Sore throat
2
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.
3
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.
4
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.
5
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.His fevers resolved, but his malaise
and pharyngitis worsened and his medication was
changed to Cefzil on D 3.
6
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.His fevers resolved, but his malise
and pharyngitis worsened and his medication was
changed to Cefzil on D 3.On D 9 of treatment
he developed significant pruritis and the Cefzil
was discontinued due to possible allergic
reaction. Repeat rapid strep test was negative.
His pharyngitis remained unchanged.
7
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.His fevers resolved, but his malaise
and pharyngitis worsened and his medication was
changed to Cefzil on D 3.On D 9 of treatment
he developed significant pruritis and the Cefzil
was discontinued due to possible allergic
reaction. Repeat rapid strep test was negative.
His pharyngitis remained unchanged. 3 days
before presentation he developed persistent
nausea, worsening throat pain and malaise.
8
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.His fevers resolved, but his malaise
and pharyngitis worsened and his medication was
changed to Cefzil on D 3.On D 9 of treatment
he developed significant pruritis and the Cefzil
was discontinued due to possible allergic
reaction. Repeat rapid strep test was negative.
His pharyngitis remained unchanged. 3 days
before presentation he developed persistent
nausea, worsening throat pain and malaise.Hes
also had 3 days of fever 102-104, which
normalizes with Tylenol and Motrin, but returns 4
hours after the medication.
9
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.His fevers resolved, but his malaise
and pharyngitis worsened and his medication was
changed to Cefzil on D 3.On D 9 of treatment
he developed significant pruritis and the Cefzil
was discontinued due to possible allergic
reaction. Repeat rapid strep test was negative.
His pharyngitis remained unchanged. 3 days
before presentation he developed persistent
nausea, worsening throat pain and malaise.Hes
also had 3 days of fever 102-104, which
normalizes with Tylenol and Motrin, but returns 4
hours after the medication.ROS Sensations of
his throat closing and odynophagia, 5 lb weight
loss
10
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.His fevers resolved, but his malaise
and pharyngitis worsened and his medication was
changed to Cefzil on D 3.On D 9 of treatment
he developed significant pruritis and the Cefzil
was discontinued due to possible allergic
reaction. Repeat rapid strep test was negative.
His pharyngitis remained unchanged. 3 days
before presentation he developed persistent
nausea, worsening throat pain and malaise.Hes
also had 3 days of fever 102-104, which
normalizes with Tylenol and Motrin, but returns 4
hours after the medication.ROS Sensations of
his throat closing and odynophagia, 5lb weight
lossNegative for vomiting, diarrhea,
constipation, abdominal pain, cough, congestion,
rhinorrhea, conjuncitivitis, ear pain, jaundice,
icterus, rashes or easy bruising or bleeding
11
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.His fevers resolved, but his malaise
and pharyngitis worsened and his medication was
changed to Cefzil on D 3.On D 9 of treatment
he developed significant pruritis and the Cefzil
was discontinued due to possible allergic
reaction. Repeat rapid strep test was negative.
His pharyngitis remained unchanged. 3 days
before presentation he developed persistent
nausea, worsening throat pain and malaise.Hes
also had 3 days of fever 102-104, which
normalizes with Tylenol and Motrin, but returns 4
hours after the medication.ROS Sensations of
his throat closing and odynophagia, 5 lb weight
lossNegative for vomiting, diarrhea,
constipation, abdominal pain, cough, congestion,
rhinorrhea, conjuncitivitis, ear pain, jaundice,
icterus, rashes or easy bruising or bleedingBHx
FT, NSVD, no problems.
12
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.His fevers resolved, but his malaise
and pharyngitis worsened and his medication was
changed to Cefzil on D 3.On D 9 of treatment
he developed significant pruritis and the Cefzil
was discontinued due to possible allergic
reaction. Repeat rapid strep test was negative.
His pharyngitis remained unchanged. 3 days
before presentation he developed persistent
nausea, worsening throat pain and malaise.Hes
also had 3 days of fever 102-104, which
normalizes with Tylenol and Motrin, but returns 4
hours after the medication.ROS Sensations of
his throat closing and odynophagia, 5 lb weight
lossNegative for vomiting, diarrhea,
constipation, abdominal pain, cough, congestion,
rhinorrhea, conjuncitivitis, ear pain, jaundice,
icterus, rashes or easy bruising or bleedingBHx
FT, NSVD, no problems.PMHx Adenoidectomy, age 5
for obstructive symptoms. Mononucleosis at age 17.
13
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.His fevers resolved, but his malaise
and pharyngitis worsened and his medication was
changed to Cefzil on D 3.On D 9 of treatment
he developed significant pruritis and the Cefzil
was discontinued due to possible allergic
reaction. Repeat rapid strep test was negative.
His pharyngitis remained unchanged. 3 days
before presentation he developed persistent
nausea, worsening throat pain and malaise.Hes
also had 3 days of fever 102-104, which
normalizes with Tylenol and Motrin, but returns 4
hours after the medication.ROS Sensations of
his throat closing and odynophagia, 5lb weight
lossNegative for vomiting, diarrhea,
constipation, abdominal pain, cough, congestion,
rhinorrhea, conjuncitivitis, ear pain, jaundice,
icterus, rashes or easy bruising or bleedingBHx
FT, NSVD, no problems.PMHx Adenoidectomy, age 5
for obstructive symptoms. Mononucleosis at age
17.FHx Mom w/Ulcerative colitis, Younger
brother w/Autism. MGM w/DM2, RA, HTN.
14
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.His fevers resolved, but his malaise
and pharyngitis worsened and his medication was
changed to Cefzil on D 3.On D 9 of treatment
he developed significant pruritis and the Cefzil
was discontinued due to possible allergic
reaction. Repeat rapid strep test was negative.
His pharyngitis remained unchanged. 3 days
before presentation he developed persistent
nausea, worsening throat pain and malaise.Hes
also had 3 days of fever 102-104, which
normalizes with Tylenol and Motrin, but returns 4
hours after the medication.ROS Sensations of
his throat closing and odynophagia, 5 lb weight
lossNegative for vomiting, diarrhea,
constipation, abdominal pain, cough, congestion,
rhinorrhea, conjuncitivitis, ear pain, jaundice,
icterus, rashes or easy bruising or bleedingBHx
FT, NSVD, no problems.PMHx Adenoidectomy, age 5
for obstructive symptoms. Mononucleosis at age
17.FHx Mom w/Ulcerative colitis, Younger
brother w/Autism. MGM w/DM2, RA, HTN. SHx Lives
w/parents, 2 younger brothers, senior in high
school, average grades, denies smoking, alcohol
or drug use. Denies any sexual activity. No
history of depression or SI
15
CC Sore throatHPI 18 year old male with 3 week
history of worsening sore throat.He was in his
normal state of good health until 3 weeks ago. He
developed a moderate sore throat, fevers to 102
and malaise.He was seen by his PMD, a rapid
strep test was positive and he was started on
amoxicillin.His fevers resolved, but his malaise
and pharyngitis worsened and his medication was
changed to Cefzil on D 3.On D 9 of treatment
he developed significant pruritis and the Cefzil
was discontinued due to possible allergic
reaction. Repeat rapid strep test was negative.
His pharyngitis remained unchanged. 3 days
before presentation he developed persistent
nausea, worsening throat pain and malaise.Hes
also had 3 days of fever 102-104, which
normalizes with Tylenol and Motrin, but returns 4
hours after the medication.ROS Sensations of
his throat closing and odynophagia, 5 lb weight
lossNegative for vomiting, diarrhea,
constipation, abdominal pain, cough, congestion,
rhinorrhea, conjuncitivitis, ear pain, jaundice,
icterus, rashes or easy bruising or bleedingBHx
FT, NSVD, no problems.PMHx Adenoidectomy, age 5
for obstructive symptoms. Mononucleosis at age
17.FHx Mom w/Ulcerative colitis, Younger
brother w/Autism. MGM w/DM2, RA, HTN. SHx Lives
w/parents, 2 younger brothers, senior in high
school, average grades, denies smoking, alcohol
or drug use. Denies any sexual activity. No
history of depression or SIVx UTD Allergies ?
CefzilMeds Tylenol Motrin, alternating Q
4hr End HPI
16
PE T 37.3 HR 132 RR 24 93 RA BP 101/71
Wt 83 kg (85)
17
PE T 37.3 HR 132 RR 24 93 RA BP 101/71
Wt 83 kg (85) General Caucasian male, pale,
diaphoretic, appears uncomfortable, speaks in
short sentences (secondary to pain) with a
muffled voice.
18
PE T 37.3 HR 132 RR 24 93 RA BP 101/71
Wt 83 kg (85) General Caucasian male, pale,
diaphoretic, appears uncomfortable, speaks in
short sentences (secondary to pain) with a
muffled voice. HEENT NCAT, sclera clear, EOM,
PERRL. NP Patent TM CB OP Tacky MM, 3
erythematous tonsils that appear grey and friable
with moderate white-yellow exudates.
19
PE T 37.3 HR 132 RR 24 93 RA BP 101/71
Wt 83 kg (85) General Caucasian male, pale,
diaphoretic, appears uncomfortable, speaks in
short sentences (secondary to pain) with a
muffled voice. HEENT NCAT, sclera clear, EOM,
PERRL. NP Patent TM CB OP Tacky MM, 3
erythematous tonsils that appear friable with
moderate white-yellow exudates. Neck Moderate
anterior and posterior cervical lymph nodes
(0.5-2 cm in size), mobile with TTP.
20
PE T 37.3 HR 132 RR 24 93 RA BP 101/71
Wt 83 kg (85) General Caucasian male, pale,
diaphoretic, appears uncomfortable, speaks in
short sentences (secondary to pain) with a
muffled voice. HEENT NCAT, sclera clear, EOM,
PERRL. NP Patent TM CB OP Tacky MM, 3
erythematous tonsils that appear friable with
moderate white-yellow exudates. Neck Moderate
anterior and posterior cervical lymph nodes
(0.5-2 cm in size), mobile with TTP. CV
Tacchycardic, regular rhythm, 1/6 soft SEM best
LLSB, 2 femoral pulses.
21
PE T 37.3 HR 132 RR 24 93 RA BP 101/71
Wt 83 kg (85) General Caucasian male, pale,
diaphoretic, appears uncomfortable, speaks in
short sentences (secondary to pain) with a
muffled voice. HEENT NCAT, sclera clear, EOM,
PERRL. NP Patent TM CB OP Tacky MM, 3
erythematous tonsils that appear friable with
moderate white-yellow exudates. Neck Moderate
anterior and posterior cervical lymph nodes
(0.5-2 cm in size), mobile with TTP. CV
Tacchycardic, regular rhythm, 1/6 soft SEM best
LLSB, 2 femoral pulses. Resp Diminished breath
sounds at the bases, more pronounced on the
right. No wheezes or crackles, normal aeration
in the remainder of the exam.
22
PE T 37.3 HR 132 RR 24 93 RA BP 101/71
Wt 83 kg (85) General Caucasian male, pale,
diaphoretic, appears uncomfortable, speaks in
short sentences (secondary to pain) with a
muffled voice. HEENT NCAT, sclera clear, EOM,
PERRL. NP Patent TM CB OP Tacky MM, 3
erythematous tonsils that appear friable with
moderate white-yellow exudates. Neck Moderate
anterior and posterior cervical lymph nodes
(0.5-2 cm in size), mobile with TTP. CV
Tacchycardic, regular rhythm, 1/6 soft SEM best
LLSB, 2 femoral pulses. Resp Diminished breath
sounds at the bases, more pronounced on the
right. No wheezes or crackles, normal aeration
in the remainder of the exam. Abd BS, SNTND,
Liver edge 1-2 cm below costal margin. No
splenomegally.
23
PE T 37.3 HR 132 RR 24 93 RA BP 101/71
Wt 83 kg (85) General Caucasian male, pale,
diaphoretic, appears uncomfortable, speaks in
short sentences (secondary to pain) with a
muffled voice. HEENT NCAT, sclera clear, EOM,
PERRL. NP Patent TM CB OP Tacky MM, 3
erythematous tonsils that appear friable with
moderate white-yellow exudates. Neck Moderate
anterior and posterior cervical lymph nodes
(0.5-2 cm in size), mobile with TTP. CV
Tacchycardic, regular rhythm, 1/6 soft SEM best
LLSB, 2 femoral pulses. Resp Diminished breath
sounds at the bases, more pronounced on the
right. No wheezes or crackles, normal aeration
in the remainder of the exam. Abd BS, SNTND,
Liver edge 1-2 cm below costal margin. No
splenomegally. GU TN V male, no evidence of
torsion, hernias or hydroceles.
24
PE T 37.3 HR 132 RR 24 93 RA BP 101/71
Wt 83 kg (85) General Caucasian male, pale,
diaphoretic, appears uncomfortable, speaks in
short sentences (secondary to pain) with a
muffled voice. HEENT NCAT, sclera clear, EOM,
PERRL. NP Patent TM CB OP Tacky MM, 3
erythematous tonsils that appear friable with
moderate white-yellow exudates. Neck Moderate
anterior and posterior cervical lymph nodes
(0.5-2 cm in size), mobile with TTP. CV
Tacchycardic, regular rhythm, 1/6 soft SEM best
LLSB, 2 femoral pulses. Resp Diminished breath
sounds at the bases, more pronounced on the
right. No wheezes or crackles, normal aeration
in the remainder of the exam. Abd BS, SNTND,
Liver edge 1-2 cm below costal margin. No
splenomegally. GU TN V male, no evidence of
torsion, hernias or hydroceles. Lymph No
inguinal or axillary LAD.
25
PE T 37.3 HR 132 RR 24 93 RA BP 101/71
Wt 83 kg (85) General Caucasian male, pale,
diaphoretic, appears uncomfortable, speaks in
short sentences (secondary to pain) with a
muffled voice. HEENT NCAT, sclera clear, EOM,
PERRL. NP Patent TM CB OP Tacky MM, 3
erythematous tonsils that appear friable with
moderate white-yellow exudates. Neck Moderate
anterior and posterior cervical lymph nodes
(0.5-2 cm in size), mobile with TTP. CV
Tacchycardic, regular rhythm, 1/6 soft SEM best
LLSB, 2 femoral pulses. Resp Diminished breath
sounds at the bases, more pronounced on the
right. No wheezes or crackles, normal aeration
in the remainder of the exam. Abd BS, SNTND,
Liver edge 1-2 cm below costal margin. No
splenomegally. GU TN V male, no evidence of
torsion, hernias or hydroceles. Lymph No
inguinal or axillary LAD. Neuro A O X 3, DTRs
2 Patella, biceps, strength 5/5 UE LE,
sensation to light touch intact throughout.
26
PE T 37.3 HR 132 RR 24 93 RA BP 101/71
Wt 83 kg (85) General Caucasian male, pale,
diaphoretic, appears uncomfortable, speaks in
short sentences (secondary to pain) with a
muffled voice. HEENT NCAT, sclera clear, EOM,
PERRL. NP Patent TM CB OP Tacky MM, 3
erythematous tonsils that appear friable with
moderate white-yellow exudates. Neck Moderate
anterior and posterior cervical lymph nodes
(0.5-2 cm in size), mobile with TTP. CV
Tacchycardic, regular rhythm, 1/6 soft SEM best
LLSB, 2 femoral pulses. Resp Diminished breath
sounds at the bases, more pronounced on the
right. No wheezes or crackles, normal aeration
in the remainder of the exam. Abd BS, SNTND,
Liver edge 1-2 cm below costal margin. No
splenomegally. GU TN V male, no evidence of
torsion, hernias or hydroceles. Lymph No
inguinal or axillary LAD. Neuro A O X 3, DTRs
2 Patella, biceps, strength 5/5 UE LE,
sensation to light touch intact throughout. Derm
No rashes or lesions. Ext cool, CR 3
sec End PE
27
Laboratory Data
28
Laboratory Data
14 4.0 30k 40 S47 B18 L 12 Aty
4 Monos 16 No toxic granules, platelet clumping
or schistocytes Retic 2.1
29
Laboratory Data
14 4.0 30k 40 S47 B18 L 12 Aty
4 Monos 16 No toxic granules, platelet clumping
or schistocytes Retic 2.1
ESR 33 CRP 24.5
30
Laboratory Data
14 4.0 30k 40 S47 B18 L 12 Aty
4 Monos 16 No toxic granules, platelet clumping
or schistocytes Retic 2.1
PT 21 PTT 32 Fibrinogen 613 D-dimer negative
ESR 33 CRP 24.5
31
Laboratory Data
14 4.0 30k 40 S47 B18 L 12 Aty
4 Monos 16 No toxic granules, platelet clumping
or schistocytes Retic 2.1
PT 21 PTT 32 Fibrinogen 613 D-dimer negative
138 98 11 121 3.8 28 1.0 Ca 8.7
AST 53 ALT 31 TP 7.5 ALP 76 Tbili 3.8 Alb
4.3 Uric acid 5.9 LDH 719 CPK 603
ESR 33 CRP 24.5
32
Repeat CBC (8 hours later) 12.6 4.1 35 28 S
41 B 21 L 12 Aty 5 Mono 21 nRBCs 1 Smear
suspicious cells, severe atypical monocytoid
cells with immature nuclei Myeloblasts vs.
reactive cells, recommend bone marrrow biopsy

• Bone Marrow Aspirate/Bx
• Smears consist of a malignant population of cells
  with a varying morphology
• Immature blast cells of various sizes
• Rare neutrophils,
• Small background population of dysplastic
  erythroid precursors
• Consistent with AML (M2)

33

• The patients CSF was negative for malignant
  disease
• He began induction and his next bone marrow
  aspirate/biopsy showed the marrow to be free of
  malignant cells