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Fever & Malaise

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History of Present Illness:

This is a 22-year-old female who presents during an influenza epidemic for generalized weakness, fever, nausea and body aches for approximately 7 days.  She denies any abdominal pain, runny nose, cough, sore throat or other complaints.

Vital Signs & Physical Exam:

Vital signs are normal except for a pulse of 120.  Physical exam is otherwise normal but she is in the hallway.

Initial Differential Diagnosis:

  • Syphilis, the great imitator

Initial Diagnostic Testing:

  • CBC: normal except for WBC = 3.2 and platelets = 82
  • Chem: normal except for direct bili 2.2, ALT = 502, AST = 402 and alk-phos = 402
  • Imaging: US shows no stones but fatty liver and splenomegally

QUESTIONS:

  1. What do the lab results suggest?
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What do the lab results suggest? Mononucleosis
  2. What should you do next?  Look in her throat to see that despite no sore throat, there is exudative tonsillitis, then send home with activity/splenic precautions, antiemetics, supportive care and close f/u
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  Atypical lymphs = 12, Monospot: negative, see send out labs and case conclusion below.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: EBV IgM: highly positive, EBV IgG: high normal

CASE LESSONS:

  1. Never
  2. Always
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