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Case Write up

Patients Demographics

Name Initials: M.A

Age: 17 years old.
Gender: Female.

Admission Details

Date of admission: 9/02/2023

Time of admission: 11:00 pm.
Patient location: Med 4 TW; 04; A
Source of information: Patient
Reason of admission: Headache and fever.

Chief complaint

M.A presented due headache and fever for 2 weeks.

History of Presenting Illness

M.A came to the emergency department due to a two-week history of headache and
fever. The headache is generalized, pulsatile in nature, started two weeks ago after returning
from school. It has been gradually increasing in intensity and does not radiate, with a rating of
9/10. It is present all the time and is relieved by pain killers such as Panadol and Ibuprofen, the
headache is more pronounced at night, but it is not positional. There is no neck pain or
confusion, photophobia or phonophobia. She has been experiencing vomiting with the headaches
2-3 times a day, which is watery and non-bloody, moderate in amount and accompanied with
nausea. The vomiting has decreased her appetite and she preferred drinking water ever since. She
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has mild dysuria that started at the time of the vomiting, severity of 3/10. There is no changes in
frequency of urination, and the urine is dark with no blood, foul smell, constipation, or diarrhea.
M.A’s intermittent fever started gradually with a max 40 degrees Celsius, relieved by
taking Panadol aggravated at night. Associated with fatigue and had generalized weakness, joint
pain and chills but no sweats. She denies having any earache, sore throat, shortness of breath,
chest pain, and skin rashes.
She mentions recent respiratory tract infection one week ago.

Past Medical, Surgical, Mental History

 Past medical history:

 Diagnosed recently with iron and vitamin D deficiency.
 Otherwise, past medical and surgical history is negative
 Mental health:
 Within normal limits
 No past history of psychiatric disorders or hospitalizations.

Medications and Allergies and Adverse Reactions

 No current medication use except for Panadol.

 Allergic to black seeds. No history of anaphylaxis.

Family History

 Father: Negative.
 Mother: Negative .
 Sisters: one sister with negative history.
 Brothers: 2 brothers with negative history.
 Maternal grandmother: Diabetes Mellitus Type 2.
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 Maternal grandfather: Hypertension.
 Paternal grandmother: Negative.
 Paternal grandfather: Negative.

Social History

 A.N is single.
 Student.
 Reports no history of smoking, No one in the household smokes.
 No history of alcohol use.

Provisional Diagnosis

1. Meningitis:
Supporting Factors:
 Generalized and pulsatile headache with gradually increasing intensity for 2 weeks.
 Vomiting 2-3 times a day accompanied by nausea and decreased appetite.
 Fever that reached up to 40 degrees Celsius
 Fatigue and generalized weakness with joint pain and chills
 Exclusion Factors:
 No neck pain or confusion.
 No photophobia or phonophobia.
2. Viral illness:
Supporting factors:
 Gradual onset of fever
 Fatigue
 Generalized weakness
 Joint pain and chills
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Physical Exam

General appearance: M.A was lying comfortably on the bed during the physical exam.
 She had a low grade fever of 37.7 C.
 She was connected to a BP monitor which showed a reading of 123/68bpm.
 Her Heart Rate was 97bmp.
 Her oxygen saturation was 100% on room air.
 One cannulas was present, on the right side connected to normal saline.
 Weight: 49 kg
 Height: 151cm.
 BMI: 21.45kg/m2.
Full Physical Exam:
Head and Neck:
 Eyes: Pupils equal, round and reactive to light, no nystagmus or diplopia, conjunctiva
clear.
 Mouth and throat: Inflamed and enlarged tonsillitis with few whitish exudate.
Peritonsillar LN right side palpable. No trismus, no uvular deviation, or pharyngeal
erythema.
Chest and Lungs:
 Respirations are regular with no wheezing, rales or rhonchi.
 Lungs clear to auscultation bilaterally.
Cardiovascular:
 Regular rate and rhythm, no murmurs or gallops, peripheral pulses are 2+ bilaterally.
Abdomen:
 Soft, non-tender, mild distention, The liver was palpable 3 cm below the right costal
margin with a span of 14 cm and was tender to palpation, spleen palpable 4 cm below
costal margin. No masses or organomegaly palpable. Bowel sounds present and
normoactive.
Musculoskeletal:
 No swelling, erythema or deformity, full range of motion in all extremities.
Neurological:
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 Alert and oriented to person, place and time
 Cranial nerves II - XII intact
 No motor or sensory deficits
 No cerebellar abnormalities
 No abnormal reflexes
Lymphatic:
 Enlarged, tender cervical and axillary lymph nodes bilaterally
 No inguinal lymphadenopathy.

Diagnosis and Investigations:

 Infectious Mononucleosis (EBV):

 Inclusion:
 Presence of fever, tonsillitis, and hepatosplenomegaly
 Fatigue, malaise, and anorexia
 Absence of respiratory symptoms and skin rash
 Exclusion:
 Absence of lymphadenopathy, fatigue, and myalgia more than 1 week
prior
 Group A Streptococcus:
 Inclusion:
 Presence of high fever, sore throat, and tonsillitis
 Enlarged tender cervical lymph nodes
 Exclusion:
 Absence of sandpaper-like rash or strawberry tongue
 Cytomegalovirus (CMV):
 Inclusion:
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 Presence of fever, fatigue, and malaise
 Presence of mild hepatitis

Investigations Needed:
1. Complete blood count (CBC) with differential - to evaluate for leukocytosis, atypical
lymphocytes, and anemia.
2. Monospot test (heterophile antibodies) or EBV viral capsid antigen (VCA) - to evaluate
for infectious mononucleosis.
3. Throat culture or rapid strep test - to evaluate for group A streptococcus. Anti-
streptolysin O (ASO) titers - to evaluate for recent streptococcal infection.
4. Serum serology for cytomegalovirus (CMV) - to evaluate for CMV infection.
5. Blood culture - to evaluate for bacteremia.
6. Liver function tests (LFTs) - to evaluate for hepatocellular injury or cholestasis.
7. Abdominal ultrasound or CT scan - to evaluate for hepatosplenomegaly or
lymphadenopathy.
8. Chest X-ray - to evaluate for pneumonia or other respiratory infections.
Investigations done:
CBC:
- WBC 11.4x10^9/L
- RBC 4.50 x10^12/L
- Hgb 113 g/L (low)
- Hct 0.31 L/L (low)
- MCV 68.4 fL (LOW
- MCH 25.1 pg (LOW)
- MCHC 367 g/L (high)
- Platelet 308 x10^9/L
- RDW-CV 16.9 % (HI)
- MPV 10.80 fL
- Neutro #: 3.08x10^9/L
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- Lymph #: 6.73x10^9/L (high)
- Mono#: 0.57x10^9/L
- Eos #: 0.00x10^9/L
- Baso#: 0.11x10^9/L
Electrolytes: (to correct any abnormalities)
- Sodium Lvl 139 mmol/L
- Potassium Lvl 3.9 mmol/L
- Chloride Lvl 103 mmol/L
- Urea level: 1.00mmol/L (low)
- Albumin: 32 g/L (low)
- Bili total: 18.1 micromol/L(HI)
- Bili direct: 15.7 micromol/L(HI)
- Alk Phos: 233 IU/L (HI)
- GGT:259 IU/L (HI)
- AST: 203 IU/L (HI)
- ALT: 254 IU/L (HI)
- Ferritin: 345mcg/L (high)
- Vitamin B12: 1,249 pmc
- TIBC:41micromol

Blood film:
Anisocytosis: 1+
Microcytes: 2+
Poikilocytosis: 1+
Elliptocytes: 1+
Tear Drop Cells: 1+
Hypochromasia: 1+
Schistocytes: 1+
Respiratory cultures: No group A beta hemolytic streptococci isolated.
Immunology:
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HIV Ag/Ab Screen: Negative
Hepatitis Bs Ag Screen: Negative
Hep Be Ag: Negative
Hep Be Ab: Negative
AMA Screen: Negative
ANA: Negative
EBV Capsid Antigen IgG: Positive
EBV Capsid Antigen IgM: Positive
EBV Nuclear Antigen IgG: Negative
Hepatitis C Ab Screen: Negative
Mono Scrn: Positive
Hep A IgG: Positive
Hep A IgM Ab: Negative

US hepatobiliary System:
- The liver is of borderline size measuring 16.1 cm in span with normal shape and outline
with no focal lesion.
- No intrahepatic biliary tree dilatation.
- No gallstones or wall thickening.
- Few prominent porta hepatis lymph nodes, the largest measures 1.2 cm in short axis.
- The visualised part of pancreas is unremarkable.
- The spleen is slightly bulky measuring 14.1 cm in span with no gross focal lesion.
- No free fluid.
- normal variation.
- CTA images are within normal limits.

Chest X-Ray and Abdominal X-ray: Negative

Final Diagnosis
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EBV Mononucleosis

Management

Upon admission:
- Initial evaluation and stabilization:
The patient should be evaluated to ensure she is stable and her airway, breathing, and
circulation are adequate. Vital signs, including temperature, heart rate, blood pressure, and
oxygen saturation should be monitored.
- Symptomatic relief:
Symptomatic treatment of our patient symptoms should be initiated. This includes
prescribing analgesics, such as acetaminophen, for pain relief and antipyretics to control
fever. Avoid NSAIDs for her liver.
- Rest and hydration:
The patient should be advised to rest and stay hydrated by drinking plenty of fluids if she can
tolerate orally. Intravenous fluids may be required if unable to tolerate oral fluids.
- Monitoring for complications:
The patient should be monitored for complications, including airway obstruction, splenic
rupture, and neurological complications.
Outpatient treatment:
- Avoid sports for at least the first 21 days.
- Counseling: Counseling should be provided to the patient and their family on the self-
limiting nature of the disease, avoiding contact sports or heavy lifting, and the importance
of rest and hydration.

Secondary Prevention:
1. Frequent handwashing. Not sharing utensils, drinking glasses, and toothbrushes.
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