Identifying Data

 

Time 3/26/19, 12pm

Name: L.S.

Sex: female

Age: 38

Race: Hispanic

Nationality: American

Marital status: Single

Location: Yonkers

Source of information: self, pt is reliable

 

Chief complaint: “I’ve been feeling very weak and tired” x3 weeks

 

HPI:

38 y/o female with PMHx asthma of presents today for fatigue x3 weeks. Pt admits to sore throat, chills, fatigue, joint pain, decreased appetite. Pt states that the fatigue has been consistent since onset and that she has been able to go to work, but she is tired all the time, and “everything is harder to do these days”. Pt admits to feeling feverish at times. Pt states that she has a sharp pain in her throat, making it harder to eat and drink. Pt denies cough, SOB, dizziness, recent weight change, sick contacts, or recent travel.

 

DDx:

• Infectious Mononucleosis: consistent with the symptoms of fatigue, achy joints, fever, sore throat.
• Lyme disease: consistent with achy joints, fatigue, malaise, fever, although there is no history of being in the woods or near tall grass

 

Past medical history:

Present illnesses: mild intermittent asthma, well controlled

Past hospitalizations: denies

Immunizations: up to date, refuses influenza vaccine

Screenings: Last pap 5/20/16

Surgical history: denies

Past injuries and transfusions: denies

Allergies: denies environmental, food and drug allergies

 

Medications:

Ventolin HFA 90mcg, PRN

Birth control pill

 

Family History:

Maternal grandmother: deceased 75 y/o -old age; history of hypertension x 20 yrs, and dementia x 3 yrs

Maternal grandfather: deceased 70 y/o- acute MI; history of hyperlipidemia x 6 yrs

Paternal grandmother: deceased 86 y/o- lung cancer x 4 yrs; 40 pack-yr smoking history

Paternal grandfather: deceased 90 y/o- old age

Mother: Alive and well- 65 y/o- HTN x 15 yrs, Asthma x55 yrs

Father: alive and well 70 y/o- HTN x20 yrs, HLD x10 yrs

 

Social History:

L.S. is a female, living with her long-time boyfriend and a dog. She works as a receptionist.

Habits: admits to drinking socially on with weekends when she goes out with her friends, usually 2-3 glasses of wine or a couple of mixed drinks. She drinks 1 cup of caffeinated coffee in the morning. She denies smoking

Travel: none

Diet: a lot of fast food, she is trying to cook more.

Exercise: yoga 1-2x/week

Safety measures: admits to wearing a seatbelt

Sleep: 5-6 hrs/night

Sexual history: sexually active with one male partner, she is on birth control pill, they don’t use condoms, denies history of STIs

 

Review of Systems:

General: admits to fatigue, weakness, chills, fever, loss of appetite. Denies fever, night sweats, recent weight loss or gain.

Skin, hair, and nails: denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritis and changes in hair distribution.

Head: Admits to headache, denies, vertigo, head trauma, unconsciousness, coma, fracture.

Eyes: denies wearing glasses or contacts, visual disturbances, fatigue, lacrimation, photophobia or pruritis. Last eye exam: November 2017: 25/20 OS,25 /20 OD, 25/20 OU.

Ears: denies deafness, pain, discharge, tinnitus, and hearing aids

Nose/sinuses: denies discharge, epistaxis, and obstruction

Mouth and Throat: admits to sore throat, denies bleeding gums, sore tongue, mouth ulcers, voice changes, or dentures. Last dental exam was September 2018

Neck: denies localized swelling/lumps, stiffness/decreased range of motion

Breast: denies lumps, nipple discharge and pain

Pulmonary System: Denies dyspnea, orthopnea, SOB, PND cough, wheezing, hemoptysis and cyanosis.

Cardiovascular: Denies HTN, edema, chest pain, palpitations, irregular heartbeat, and syncope.

Gastrointestinal system: Admits to decreased appetite, denies intolerance to foods, nausea, vomiting, hemorrhoids, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, constipation, rectal bleeding, blood in stool, pain in flank

Sexual Activity: sexually active, one male partner, does not use condoms, denies history of STIs.

Menstrual/Obstetrical – G0P0, Menarche age 13. LMP 3/15/19. Denies breakthrough bleeding/spotting or vaginal discharge.

Nervous – Admits to headaches, denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system: admits to muscle/joint pain, denies deformity of swelling, redness or arthritis

Peripheral vascular system: Denies varicose veins, peripheral edema, intermittent claudication, coldness or trophic changes, or color change

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional

 

Physical Exam:

 

General: female of average height and weight, appears tired, but not in any acute distress, neatly groomed, looks stated age, good hygiene, good posture, A/Ox3

 

Vital signs: BP 110/75, HR 77 regular, O2 97% (room air), RR 16 unlabored, T 98.6 F, height 66 inches, weight 143 lb, BMI 23.08

 

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.
Hair: average quantity and distribution.
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: normocephalic, atraumatic, non-tender to palpation throughout.

Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear.
Visual fields full OU. PERRLA, EOMs full with no nystagmus.

Ears: Symmetrical and normal size. No evidence of lesions/masses/trauma on external ears.
No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/intact with light reflex in normal position AU..

Nose: Symmetrical, no obvious masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/deformities/injection/perforation. No evidence of foreign bodies.

 

Sinuses: Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Lips: Pink, moist; no evidence of cyanosis or lesions. Non-tender to palpation.
Mucosa: Pink; well hydrated. No masses; lesions noted. Non-tender to palpation. No evidence of leukoplakia.
Palate: Pink; well hydrated. Palate intact with no lesions; masses; scars. Non-tender to palpation.
Teeth: Pt wears dentures.
Gingivae: Pink; moist. No evidence of hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.
Tongue: Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.
Oropharynx: Pharyngeal inflammation and erythema present without exudate. Injected oropharynx; well hydrated; no evidence of exudate; masses; lesions; foreign bodies. Tonsils present with injection. Uvula pink, no edema, lesions.

 

Neck: palpable posterior cervical adenopathy present. Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills or bruits noted bilaterally.
Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Heart: PMI in the 5^th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruit. RRR. S1 and S2 are present. No S3, S4, splitting of heart sounds, or murmurs present.

Chest: symmetrical, no deformities, no evidence of trauma. Respirations unlabored/ o paradoxical respirations or use of accessory muscles notes. Lat to AP diameter 2:1. Non-tender to palpation

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No adventitious sounds.

Abdomen: Flat, symmetrical, no evidence of scars, striae, caput medusae or abnormal pulsations, BS present in all four quadrants. No bruits noted over aortic, renal, iliac, femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.

 

Extremities: Full range of motion, no edema, erythema, or deformities. Pulses intact throughout. No clubbing or cyanosis. Capillary refill <2 seconds throughout.

 

DDx:

• Infectious mononucleosis
  • Mono is consistent with the pts presentation of fatigue, sore throat, posterior adenopathy, there was no splenomegaly on exam
• Lyme
  • Although the pt does not has a rash, not all cases present with the textbook rash. Lyme is a possibility because of the fatigue x3 weeks, malaise, fever, achy joints.
• GERD
  • GERD can explain the sore and irritated throat. Additionally, it can interfere with sleep which would lead to fatigue, weakness and the feeling of tiredness

Labs:

• CBC:
  • WBC 11.6
  • Lymphocytosis 65%
• Thyroid panel: WNL
• CMP: WNL
• Hepatic function: WNL
• Mono Spot: Positive
• Lyme Disease AB: negative

Assessment

35 yo Hispanic female with PMHx of asthma presents with fatigue, pharyngitis, posterior lymphadenopathy, decreased appetite consistent with infectious mononucleosis

 

Plan:

1. Mononucleosis:
   1. rest as needed
   2. Increase hydration
   3. OTC analgesia
   4. Advise the pt to refrain from any contact sports
2. Asthma:
   1. continue using Albuterol rescue inhaler PRN

 

 

Patient Education

Mono is a virus that is commonly known at the “kissing disease” It is usually caused by the Epstein Barr virus and is most common in teenagers and young adults. Mono is spread by fluids, so you can get it by sharing utensils or food or any other contact where saliva or body fluids can be shared between people. The symptoms usually last 4-7 weeks but can differ between people. The best thing patients can do is listen to their body. Patients aren’t required to have strict bed rest but should understand that they are likely to feel fatigued for several weeks and should only exert themselves to what they feel up to.