Ophthalmology Case Study

HISTORY
Patient is an 18-year-old male who stated on Wednesday, the 2nd, he started having severe sore throat.  On Thursday, he developed temp of 103, hard to keep anything down.  They called our servi____________- called him in, Zithromax, through the phone and he was seen in our clinic on Saturday, the day of 4th.  On Saturday, we performed a rapid strep and mono, both of which were negative.  He was placed on Omnicef, but thinking this was possibly viral or mono that was missed by the mono rapid test.  Patient continued to have fever, chills, severe pain, inability to swallow, and started vomiting.  He was brought to the emergency room on the evening prior to admission.  In the ER, he underwent laboratory testing, which showed that he had severe cryptic tonsillitis or just a lot of exudate.  His electrolytes plus was normal.  His white count was 7.3, H and H was normal.  There was no shift.  Lymphocyte count was only 16%.  His mono test serum was negative.  His UA shows that he has 2+ ketones, 2+ protein.  He was admitted to the hospital for pain control, dehydration, and IV antibiotics for his tonsillitis, and Zofran for his nausea.

PAST MEDICAL HISTORY

He has no known allergies.  He uses albuterol p.r.n. for asthma.  He was hospitalized in 1995 for viral croup by myself.  Otherwise, he has been mainly treated as an outpatient.  He is up-to-date on all his shots.  He does use albuterol on a p.r.n. basis and he has used Azmacort in the past, but as he has gotten older, he has a kind of outgrown most of his bronchospasm problems.

FAMILY HISTORY

His mother is basically healthy, does have some fibromyalgia and other problems.  Father has no chronic medical problems.

SOCIAL HISTORY

He is a rising sophomore at USA.  He lives on campus.  His parents are divorced.  He lives between both of them, but mainly on the campus of the school.  He does smoke some and he has been counseled on this.  He has not smoked since Tuesday; hopefully, we can discontinue this secondary to the exacerbations of asthma that this can cause and this has been explained to him at length.

PHYSICAL EXAMINATION

GENERAL:  Patient is lying in bed, sitting up.  He said it is difficult to drink, but he has had about a 1/2 a cup in hour since he has been here.

HEENT:  Oropharynx reveals exudates bilaterally with cryptic-appearing tonsils.

NECK:  Supple, with very shoddy cervical lymph nodes, nothing prominent.

CARDIAC EXAM:  Regular.

CHEST:  Actually sounds pretty good.  He is not wheezing at this time, but he has had 2 treatments.

EXTREMITIES:  No edema.

ADMISSION DIAGNOSES

1.            Tonsillitis, most likely viral, could be cryptic tonsils with chronic bacterial.

2.            Dehydration secondary to tonsillitis.

3.            Nausea and vomiting secondary to tonsillitis.

PLAN AT THIS TIME

Hydrate with IV fluids.  We will discontinue his Rocephin and put him on Zosyn to cover anaerobes as well.  He has been given Decadron x2.  Continue pain medicines.  He should slowly defervesce.  Other cultures were obtained through the ER.