This case study is about a 22-year-old patient Ricardo Ortego, who complains of a sore throat that he has had for twenty-four hours and pain when swallowing. The first step in diagnosing such patients is differentiating between the cause of sore throat, which can be an infection, or another reason (“Sore throat,” n.d.). The provisional primary diagnosis based on this characteristic is an infectious disease, which is the most common reason for a sore throat. Since Ortego did not experience these symptoms for an extended period, the noninfectious causes are not likely to cause his symptoms.
Diseases that cause symptoms that Ortego displays can be bacterial or infectious, which can be determined through additional evaluations. The examination of Ortego’s lymph noodles shows that he has tender enlarged anterior cervical nodes on his left side. Additionally, he has a temperature of 38 degrees, which is consistent with the enlarged noodles and can be an indicator of conditions such as common cold, strep throat, tonsillitis, and several others. Notably, Ortego does not cough, and the differential diagnosis is tonsillitis.
Based on the lab results, the factors that increase the probability of developing a bacterial infection are the segmented neutrophils, which are estimated at 70%, and WBC count of 13,300/mmc. According to the definition by Medline Plus, WBC’s are the leucocytes that help the body fight infection. Hence an increased level of them supports the initial diagnosis of an infectious disease (“WBC,” n.d.). Neutrophils levels point to the bacterial nature of the infection since these white blood cells are usually released as a result of bacteria. In summary, the evaluation of this patient case suggests that Ortego has tonsilitis.