OSCE Case

S.M. is a 15-year-old female with a complaint of sore throat for 2 days. 

History Elements 

  • Pain with swallowing 
  • Pain with swallowing rated a 6/10 
  • Itchy sensation 
  • No difficulty breathing or SOB 
  • Hoarse voice 
  • Cough  
  • Fever that started today with Tmax of 100.8, measured axillary 
  • Tolerates saliva and liquids, but experiencing discomfort with solids 
  • No nausea, vomiting, or diarrhea 
  • No abdominal pain 
  • No chest pain 
  • No runny nose or sinus pain 
  • No ear pain 
  • Took Tylenol 3 hours ago for fever without any relief 
  • Feeling fatigued 
  • No recent travel 
  • No surgical history, and no pertinent family history 
  • No allergies to medications 
  • History of seasonal allergies 
  • Not sexually active 

Physical Exam

  • VS – BP: 110/70 HR: 70 SpO2: 98% T: 101 RR: 18 Wt: 112 lbs 
  • General – alert, oriented, does not appear to be in acute distress 
  • Oral Cavity – mucous membranes moist 
  • Pharynx – swelling, erythema noted, w/o exudates, uvula midline with no evidence of abscess or airway obstruction 
  • Ears – TM pearly gray, normal landmarks, light reflex present, no erythema, bulging or perforation 
  • Lymph nodes (neck) – palpable anterior cervical lymphadenopathy 
  • Abdominal – soft, non-tender, bowel sounds present, no splenomegaly 
  • Cardiac – no murmurs or gallops, S1 and S2 present 
  • Lungs – clear to auscultation bilaterally, no wheezes, rhonchi, or rales 

Differential Diagnosis 

  • Group A Strep throat – While the patient has a cough and no exudates, which does not meet the criteria for strep throat, it does not mean the patient doesn’t actually have it. The patient also has pain with swallowing, changes in voice, fever, and fatigue which are symptoms that can all be present with strep throat. Pharynx is also erythematous. There is also the fact that she could have contracted it from someone else at school who had it. 
  • Viral Pharyngitis due to Respiratory Virus– In addition to an erythematous and swollen pharynx, the patient is also experiencing a cough which is not part of the Centor criteria for strep throat. She is also 15 years old which gets zero points for the Centor criteria. There are also no exudates on exam. 
  • Non-streptococcal Pharyngitis caused by EBV– Patient is an age where she could have kissed another adolescent and could have contracted the disease. She is also experiencing a fever, fatigue, and sore throat which is erythematous and swollen. However, in non-streptococcal pharyngitis caused by acute infectious mononucleosis there is posterior cervical lymphadenopathy not anterior. You can also find exudates on exam which are not present in this case.  
  • Post-nasal drip secondary to allergies – Patient has a history of seasonal allergies and is experiencing a cough which could be caused by a post-nasal drip. Post-nasal drip can also be irritating the pharynx causing erythema and swelling. 

Tests 

  • Mono Spot – negative 
  • Rapid strep test – positive 

Treatment 

  • Amoxicillin 500 mg by mouth every 12 hours for 10 days (children over 40kg generally receive the adult dose and the max dosage is 1000 mg/day) 
  • Tylenol as needed for fever every 4-6 hours 
  • Hot liquids – to soothe throat 
  • Lozenges – to soothe throat 
  • Water, Gatorade for hydration 

Patient Counseling 

  • The patient’s throat pain should slowly improve over the next few days. It can take anywhere between 2-7 days, but most patients start to feel relief by day 3 of being on treatment. 
  • It’s important to stay hydrated, so drink plenty of fluids. Gatorade is great because it has electrolytes in it. 
  • If the patient is unable to tolerate liquids anymore, starts to drool excessively, has difficulty breathing, condition worsens, or pain continues for more than 3 days without improvement, please go to the emergency room for further evaluation and treatment.  

References

https://www.uptodate.com/contents/acute-pharyngitis-in-children-and-adolescents-symptomatic-treatment?search=patient%20counseling%20for%20strep%20throat&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H4290748635

Hartman N.D. (2020). Neck and upper airway. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.),  Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill. https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?bookid=2353&sectionid=221180188 

Symptoms & chief complaints in general medicine. Huppert L.A., & Dyster T.G.(Eds.), (2021). Huppert’s Notes: Pathophysiology and Clinical Pearls for Internal Medicine. McGraw Hill. https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?bookid=3072&sectionid=257403412