Mononucleosis
Age: years old
Gender:
HISTORY:
Presents with a - history of
Symptoms include:
, up to °, over
, , , ,
,
Worsening factors:
Alleviating factors: ,
Contributing factors:
no history of: , , ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head: , scalp
Eyes: conjunctiva/sclera , lids/lashes
Ears: tympanic membranes , auditory canal on , hearing
Nose: , discharge ,
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
Musculoskeletal: joints ,
Mental status: , , speech , mood , thought , , judgment
ASSESSMENT:
DDx: infectious mononucleosis, CMV, toxoplasmosis, acute HIV infection, herpes simplex virus infection, Covid, influenza, adenovirus infection, hepatitis, streptococcal pharyngitis, acute leukemia, lymphoma, rubella, drug reaction, secondary syphilis
PLAN:
Investigations:
- Blood work: , , , , , ,
- Throat culture
Treatments:
- Rest and hydration
-
- Avoidance of contact sports or heavy lifting
- Avoid alcohol
- leave for
Further care:
- Follow-up in with repeat LFTs
- Return if symptoms worsen or if new symptoms develop
- Referral to ER if severe abdominal pain, shortness of breath, or difficulty swallowing occurs
HISTORY: EXAM: ASSESSMENT: PLAN: