Answer

Case Study

This case study evaluates the diagnosis, treatment, and prevention of Stephanie’s condition, characterized by fatigue, fever, bone pain, sore throat, and bruising in various body places. Further assessment reveals that her liver and spleen are enlarged.

Lab Tests

Six lab tests would be essential in this case, including the complete blood count (CBC), Liver function test (LFT), USG, CT scan, blood sugars, throat culture, and antibody test. The CBC would provide sufficient information about the total cells circulating in the blood, including red blood cells, white blood cells, and platelets. It is used to detect various conditions and diseases, including leukemia, infections, and anemia. The LFT test would help evaluate the degree of liver damage and the level of various enzymes in the blood. LFT tests if the liver is effectively executing its functions, including clearing the bilirubin levels. The abdominal CT scan would be essential to determine the organs’ conditions, including the heart, liver, and lungs. The blood sugars, including random, fasting, or oral glucose tolerance, help determine diabetes. A throat culture would be essential in diagnosing bacterial infections in the throat and ruling out some of the infections, including strep. The antibody test helps in determining if Stephanie had an infection before.

Possible Results

From the CBC, it is expected that the number of white blood cells is higher than the normal range of 3.4-9.6 billion cells per liter. A high number indicates infection or inflammation; thus, the body is trying to fight it. Another expectation is elevated Serum transaminase, demonstrating liver damage. Also, the alkaline phosphatase (ALP) levels are expected to be higher than 140 IU/L. This also indicates liver damage. The increased serum transaminase and ALP are related to the increase in lymphocytes. The antibody test suggests the Epstein Barr virus.

Possible Diagnosis

The potential diagnosis is the mononucleosis infection by the Epstein Barr virus (EBV) from the results of increased serum transaminase and ALP and the antibody test. The infection mainly spreads through the body fluids, usually saliva. According to the CDC (2020), the symptoms include fever, fatigue, inflamed throat, enlarged liver and spleen, and rashes present in Stephanie’s clinical manifestations. The majority of people are infected in their childhood, the case for Stephanie, who is 7 years old.

Treatment Based on the Diagnosis

EBV has no vaccine, and according to the CDC, there is no specific treatment besides managing the particular symptoms. Both pharmacological and non-pharmacological approaches are included in the treatment. Pharmacological intervention entails medication (OTC) for the fever and pain. Paracetamol (105 mg, orally) every 4-6 hours is essential for the pain and fever. For sore throat, an antibiotic is essential. The non-pharmacological intervention includes taking plenty of water for hydration, plenty of bed rest, and avoiding contact with someone else body fluids. This can be prevented by not kissing or sharing personal items, including toothbrush and food.

Prevention of the Illness.

Stephanie’s illness could have been prevented by maintaining hygiene levels, avoiding sharing personal items, such as the toothbrush and food, or contact with toys for other children with drool. Another prevention measure is avoiding kissing. These approaches are how the virus spreads.