The Case Study/Scenario: Jason, a 13-year-old male comes in with Mom complaining of painful swallowing. Started yesterday as a “really bad sore throat” made worse with swallowing. He reports feeling very tired. His Mom gave him over-the-counter Children’s Motrin which made his fever better but did not help his sore throat

Here is a focused clinical interpretation and discussion of Jason’s case, suitable for use in a case study assignment or clinical SOAP note format:

Case Study Analysis: Jason – 13-Year-Old Male with Painful Swallowing

Chief Complaint:
Sore throat and painful swallowing for one day.

History of Present Illness:
Jason is a 13-year-old male presenting with a sudden onset of sore throat, described as very painful and worse with swallowing. The symptoms began yesterday and have worsened overnight. His mother reports he had a fever that temporarily improved with Children’s Motrin, but his throat pain remains severe. He reports fatigue, and the symptoms are most bothersome at night. He denies coughing, runny nose, or recent sick contacts.

Review of Systems:

• Positive: sore throat, odynophagia (painful swallowing), fatigue, fever (improved with medication)

• Negative: cough, nasal congestion, ear pain, rash, shortness of breath

Physical Exam Findings:

• Vital signs (assumed): Possibly febrile earlier, now afebrile due to Motrin

• Oropharynx: Tonsils 2+ and erythematous, tonsil stones (tonsilloliths) present on the right, white patches on the tongue

• Neck: Possible anterior cervical lymphadenopathy (not stated but commonly associated)

• Respiratory: Clear breath sounds, no stridor or respiratory distress

Differential Diagnosis:

1. Streptococcal pharyngitis (GAS) – sudden onset, sore throat, tonsillar erythema and exudate, fever, fatigue, and absence of cough support this diagnosis.

2. Infectious mononucleosis – especially given fatigue, white patches on the tongue (could be oral candidiasis), and tonsillar stones, though symptom duration is short.

3. Oral candidiasis – the white patches may suggest this, but it typically accompanies immunosuppression or antibiotic/steroid use.

4. Viral pharyngitis – common, but typically associated with cough, congestion, or other URI symptoms, which Jason denies.

Diagnostic Workup Recommended:

• Rapid strep test and/or throat culture to confirm or rule out Group A Streptococcus.

• Monospot test or EBV panel if symptoms persist or worsen over a few days, especially if fatigue remains prominent or lymphadenopathy/splenomegaly develops.

• Consider CBC with differential if infection severity or diagnosis remains unclear.

Management Plan:

• If rapid strep positive: initiate penicillin V 250 mg TID or amoxicillin 500 mg BID for 10 days. If allergic to penicillin, consider azithromycin 12 mg/kg on day 1, then 6 mg/kg for 4 more days.

• Provide symptomatic relief: continue Children’s Motrin for pain and fever; salt water gargles, warm fluids, throat lozenges (if appropriate for age).

• If oral candidiasis is confirmed: prescribe nystatin oral suspension (100,000 units/mL) 4 times daily swish and swallow.

• Advise rest and hydration.

• Educate on hygiene and minimizing the spread of infection.

Follow-up:

• Re-evaluate in 48–72 hours if no improvement or worsening symptoms.

• Urgent evaluation if Jason develops difficulty breathing, drooling, or neck swelling.

Parent/Patient Education:

• Importance of completing the full antibiotic course if prescribed.

• Signs of complications: persistent fever, breathing issues, severe headache, rash.