Question

Refer to Chapters 9 & 11 Read the following medical record and respond to the questions below: Medical Record sample Date: 10 Aug 20XX Patient: John Doe HISTORY: This is a 17-year-old male who comes in today with his mother with complaint of severe fatigue, fever, swollen throat and neck, no appetite, and general malaise. Mother states he has been “dragging around for the past couple weeks”. Since he wasn’t getting any better, she insisted he come in. PAST MEDICAL HISTORY: Usual childhood diseases, immunizations up-to-date. No major illnesses. SOCIAL HISTORY: Active Senior in high school. In a relationship with a steady girl friend. She is also sick with similar symptoms. PHYSICAL EXAMINATION GENERAL: 17-year-old well-developed, well-nourished male in mild distress, complaining of difficulty swallowing. VITAL SIGNS: T 101°F, P 86, R 22, BP 110/60. HEENT: Tonsils erythematous and inflamed, mild gingivitis noted. Able to swallow with mild discomfort. NECK: Enlargement of cervical lymph nodes noted. Tenderness to palpation. Limited lateral cervical neck movement. Cervical flexion and extension within normal limits. CHEST: Lungs clear, although decreased breath sounds at bases. ABDOMEN: Tenderness on palpation in upper abdomen. Mild hepatomegaly and splenomegaly. No suprapubic tenderness. Remainder of abdomen without tenderness. EXTREMITIES: Mild weakness noted. 1) What lab/diagnostic tests should be done and what diagnosis should we be concerned about?

Answer 1

1. The lab / diagnostic tests that should be done are :-

- Complete blood count

- Liver function test

- Kidney function test

- LDH

- Viral marker

- Lymph node biopsy

- Bone marrow aspiration and biopsy

- Computed tomography of neck ,abdomen ,chest and pelvis

- Chest X - Ray

Diagnosis that should be concerned of :-

- viral infection

- ALL

- HL / NHL