LifespanActivity Time: 26 min
Tina’s eight-year-old cousin comes in with a fever and sore throat. What is your differential diagnosis? What assessments and tests would you perform and why?
Model Note: Differential diagnosis includes viral pharyngitis, strep throat, influenza, cold, and sinusitis. To rule out strep, a rapid strep is indicated. Palpation of the cervical lymph nodes may demonstrate enlarged, tender, cervical lymph nodes. Visualization of the throat also gives clues to the diagnosis. White pus pockets and petechiae on the palate are classic signs of strep throat. Erythema alone may indicate viral infection or postnasal drip. If purulent discharge is noted in the posterior pharynx assess for nasal discharge and palpate the appropriate sinuses for the patient’s age. If palpation elicits pain and purulent nasal discharge is reported over the last 7-10 days, consider sinusitis. A negative rapid flu test would rule out influenza.
Tina’s 76-year-old great aunt comes into the clinic for a visit and you find that she frequently asks you to repeat what you say. During the Rinne test, you find that air conduction is greater than bone conduction in her left ear. What is your differential diagnosis? What additional assessments would you perform?
Model Note: Differential diagnosis includes sensorineural hearing loss and anatomical defects. Sensorineural hearing loss is common in old age and can be caused by heredity, diabetes, cerebrovascular disease, excessive noise, ototoxic medications, hyperlipidemia, hypothyroidism, and renal failure. Assessments should include a history of hearing impairment and ear injuries. It is important to inquire about chronic ear infection or other trauma that leads to anatomical abnormalities. An analysis of Tina’s great aunt’s medications and past medications can be used to rule out ototoxicity. Fasting glucose levels and Hgb A1C can be tested to rule out diabetes. TSH and T4 levels can rule out hypothyroidism. GFR or creatinine levels can rule out renal failure. Triglycerides, cholesterol, HDL, and LDL levels can be used to rule out hyperlipidemia. A neurological assessment should be completed to rule out cerebral ischemia. If no concrete diagnosis is made, the hearing loss should be attributed to old age.