J.J. is an 8-year-old female presenting to the primary care clinic with c/o a sore throat, body aches, and headache
Read the case below- Chief Complaint: J.J. is an 8-year-old female presenting to the primary care clinic with c/o a sore throat, body aches, and headache. Demographics: J.J is an 8-year-old white female who lives in Lakeland, Florida with her mom and dad. She is in second grade and 50 percent for height and weight on her growth charts. PMHx: Tubes in both ears due to frequent and recurring ear infections. Allergies: She has no known drug or food allergies. Lifestyle: J.J. is an active 8-year-old who plays t-ball and loves to swim. Her parents encourage plenty of fruits and vegetables and ensure she gets adequate amounts of protein in her diet each day. She is self-motivated when it comes to her schoolwork and her grades are reflective of that. HPI: An 8-year-old female presents to the primary care clinic with complaints of a sore throat and pain all over her body. Sore throat started 24 hours prior and progressively worsened. Pain feels like “swallowing glass” and patient rates a 5/10 while not trying to eat or drink but a 10/10 when trying to eat or drink anything. Chills, body aches and a fever of 100.2 is present. PE shows white exudate on both tonsils. Patient denies common symptoms in the past. Patient denies chest pain or sob. Analyze associated risk factors/demographics that contribute to the chief complaint and diEerential diagnoses: Associated risk factors include frequent interactions with pediatric population, increasing patients’ susceptibility to communicable disease. List three common diEerential diagnoses for the chief complaint, including pathophysiology and rationale, from the topic area identified on the CEA exam:
1. COVID-19: SARS-CoV-2 is an enveloped single strand RNA virus that utilizes angiotensin converting enzyme 2 receptors (ACE2) as its cell surface receptor (12- 14) (Vidya et al., 2021). Specific ACE2 receptors are expressed in epithelial cells in human lungs, intestines, kidneys, and bladders. There are new cell surface receptors such as glucose regulated protein that allow for cellular entry. Children often have mild symptoms and are spared from serious disease and poor outcomes. The most frequent symptoms include fever, cough, and fatigue with the occasional GI symptoms such as diarrhea, nausea, and vomiting. I chose this a dierential diagnosis because of symptoms aligning with patient symptoms.
2. Pneumonia: The onset of C. Pneumoniae includes elementary bodies (EBS) attaching to respiratory mucosal epithelial cells and enter through the cells by using a phagosome. Once inside the cell, the EBs reorganize to reticulate bodies (RBs) which then replicate and form intracytoplasmic inclusions (Vallejo, 2024). These infectious bodies go on to infect other cells, disrupting normal clearance mechanisms, allowing other pathogens to invade. Immune response of the host is induced by chlamydial antigens which release onto the host cell surface to replicate. Immunity is short lived, often making it possible for reinfection to happen easily. This was my second dierential due to C. Pneumonia frequently only causing
mild symptoms and can include pharyngitis, hoarseness, sinusitis, chills, and chest pain.
3. GAS: Group A Streptococcal tonsillopharyngitis is the most common bacterial cause of pharyngitis in children and adolescents. It is caused by a complex relationship between host and bacterial factors that begin the infection. GAS uses dierent virulence factors including toxins and other substances to evade the host immune system and infect humans. The capsule surrounding GAS is hyaluronic acid which allows the bacterium to evade immune detection due to similarities resembling human hyaluronic acid. GAS then produces proteases that degrade the host ability to signal immune molecules which neutralizes host immune defense. Surface substances such as lipoteichoic acid and F-protein then adhere to host cells and facilitate colonization and tissue destruction allowing GAS to invade host cells. My rationale in choosing GAS as a dierential includes GAS symptoms ranging from mild to severe including fever, sore throat, headache, nausea, vomiting, and abdominal pain.
Discuss how the three diEerential diagnoses diEer from each other in occurrence, pathophysiology, and presentation. Your discussion should compare and contrast these diagnoses rather than listing them: GAS has an occurrence of 5.2 million outpatient visits per year whereas pneumonia has 622 visits. There have been around 2.4 million outpatient visits for COVID-19 in the last year (CDC, 2024). All three can present similarly depending on the hosts immune system ranging from mild to severe. They dier in that COVID is an RNA virus that Pneumonia can be viral, bacterial, or fungal and GAS is caused by bacteria. Group A strep usually has the most rapid onset of sore throat and fever verses COVID which could take up to 14 days of incubation to start showing symptoms. Typical onset of symptoms for pneumonia is 1-3 days. In both COVID and Pneumonia you could see shortness of breath and chest pain. In strep throat you could see GI symptoms like nausea and vomiting. In both Pneumonia and COVID, infection can reach the alveoli of the lungs. In strep, the bacteria release toxins that can be damaging to local tissues like the tonsils and pharynx. In COVID you can see multi organ involvement whereas you only see systemic involvement in pneumonia mostly with sepsis. It’s rare to see systemic involvement with GAS. Describe relevant testing required to diagnose/evaluate the severity of the three diEerential diagnoses. To Diagnosis COVID, a serology and reverse transcriptase PCR on a nasopharyngeal swab is performed. Evaluating severity of disease would include performing a CBC, CRP, ESR, LFTs, serum electrolytes and kidney tests, urinalysis, troponin, and BNP (Vidya et al., 2021). The object of evaluation of a child with a cough and potential lower respiratory tract disease is to identify the syndrome be it asthma or pneumonia with consideration of the agent (bacterial, viral), and then to assess severity. Children with severe pneumonia often present with tachypnea which is greater than 40 breaths a minute. They will also show signs of respiratory distress including tachypnea and hypoxemia which is an oxygen sat level <90 percent of room air (Vallejo, 2024). Patients will show an increased work of breathing such as retractions and nasal flaring. Indications for using radiography would be to confirm the diagnosis, however this is not necessary when symptoms are present. There
is a Rapid antigen detection test for GAS with results being available at the point of care. They have a specificity of greater than 95 percent. If patient is symptomatic with clinical signs, a backup throat culture that will result in 24-48 hours should be performed. Present applicable national guidelines related to diagnosis and diagnostic testing for the diEerential diagnoses. The AAFP guideline for diagnosing strep throat is a combination of clinical evaluations and testing. Clinical symptoms include sore throat, fever, swollen lymph nodes, absence of cough and swollen tonsils with white patches. Testing recommendations include a positive RADT, and throat culture when test is negative but clinical signs and symptoms are highly indicative. The CDC recommends viral testing for COVID through a NAAT or an antigen test with the PCR being the most common (CDC, 2024). The CDC recommends looking at clinical symptoms including cough, fever, chills, and diiculty breathing along with a physical exam positive for respiratory distress and imaging like a chest x-ray to confirm a diagnosis of pneumonia. Lab tests such as sputum culture, blood tests and pleural analysis may be performed to show causative organism (CDC, 2024). Instructions below-
1. You are to share some more thoughts on management for the case above. Contribute new, novel perspectives to the discussion using original dialogue (not quotes from sources).
a. Communicate using respectful, collegial language and terminology appropriate to advanced nursing practice.
2. Professionalism in Communication: Communicate with minimal errors in English grammar, spelling, syntax, and punctuation.
3. Reference Citation: Use 2 current APA format to format citations and references and is free of errors. References need to be within 5 years. And provide the link to the website used with the references
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