Tina’s eight-year-old cousin presents at the clinic with a fever and a sore throat. What would be your differential diagnosis? Which assessments and tests would you conduct, and why?
Model Note: Possible diagnoses include viral pharyngitis, strep throat, influenza, common cold, and sinusitis. To rule out strep throat, a rapid strep test is indicated. Palpation of the cervical lymph nodes may reveal enlarged and tender lymph nodes in the neck. Visual examination of the throat also offers clues to the diagnosis. White pus pockets and petechiae on the palate are classic signs of strep throat. Erythema alone may suggest a viral infection or postnasal drip. If purulent discharge is noted in the posterior pharynx, further assessment of nasal discharge and palpation of the appropriate sinuses for the patient’s age should be conducted. If palpation elicits pain and if purulent nasal discharge has been reported over the last 7-10 days, sinusitis should be considered. A negative rapid flu test would help to rule out influenza.
Tina’s 76-year-old great aunt visits the clinic and frequently asks for repetition during conversations. During the Rinne test, you observe that air conduction is greater than bone conduction in her left ear. What is your differential diagnosis? What additional examinations would you conduct?
Model Note: Possible diagnoses include sensorineural hearing loss and anatomical defects. Sensorineural hearing loss is common in old age and can be caused by various factors such as heredity, diabetes, cerebrovascular disease, excessive noise, ototoxic medications, hyperlipidemia, hypothyroidism, and renal failure. Additional examinations should include a thorough history of hearing impairment and any past ear injuries. Inquiring about chronic ear infections or other traumas that could lead to anatomical abnormalities is essential. An analysis of Tina’s great aunt’s current and past medications can help rule out ototoxicity. Fasting glucose levels and Hgb A1C testing can be conducted to rule out diabetes. TSH and T4 levels can help assess hypothyroidism. GFR or creatinine levels can rule out renal failure. Triglycerides, cholesterol, HDL, and LDL levels can be measured to rule out hyperlipidemia. A neurological assessment should also be conducted to rule out cerebral ischemia. If a definitive diagnosis is not reached, age-related hearing loss should be considered.