Mr. F was a 16-year-old previously healthy male with a 4-day history of sore throat. He had a dry cough and nausea, but denied fever, voice changes, or sick contacts.
On initial presentation to the Emergency Department (ED), the patient’s vital signs were as follows: pulse 98 beats per minute (bpm), respiratory rate 18 cycles per minute (cpm), temp 36.7°C, and blood pressure 133/74 mmHg. Physical exam revealed bilateral tonsillar exudate and swelling (R > L). He had tender cervical lymph nodes. The uvula was midline. No palatal petechiae were noted. No splenomegaly was appreciated on physical exam.
Based on presenting symptoms, the patient received two points on the centor criteria scale (+tonsillar exudate, +cervical adenopathy) [5]. He therefore received a rapid strep test and a throat culture at his initial visit to the ED. Both tests were negative and the patient was discharged.
At a follow-up visit to the ED 2 days later, the patient complained of progressively worsening pain in his throat. He reported that the pain peaked to a 10/10 while swallowing. The patient could only tolerate a liquid diet and had significantly decreased his oral intake. He also reported nausea and intermittent dry cough. The patient denied chest pain, shortness of breath, vomiting, diarrhea, or abdominal pain.
On second presentation to the ED, the patient was now tachycardic (112 bpm) with blood pressure reduction to 111/64 mmHg. He was afebrile. Physical exam was largely unchanged from previous. Abdomen was soft and nontender. Again, no splenomegaly was appreciated on exam.
Given the negative strep throat culture from the patient’s prior visit, mononucleosis was high on the differential. Since splenic enlargement was not detected on physical exam, ultrasound imaging was performed to rule out splenomegaly.
A p21 transducer in the abdominal examination mode was used for measurement. The patient was placed in a supine position. The probe was placed posteriorly below 12th rib on the patient’s left side and angled anteriorly. The spleen was measured to be 17.8 cm in axial length (NL 11 to 13 cm).
Based on the patient’s significant splenomegaly and 4-day history of sore throat, the patient was given a presumptive diagnosis of mononucleosis. He was treated symptomatically: given IVF and anti-nausea and pain medications. After IVF, the patient’s HR decreased to 98 bpm. He was advised to avoid contact sports for the next 3 to 4 weeks. The patient was subsequently discharged with no further testing.