Finn is a 15-year-old boy who has been at the Sands Juvenile School for the past year. The school is in a rural area, and has an animal husbandry program, as well as a carpentry program.
Nursing Sick Call Evaluation
SUBJECTIVE
Finn presents to the medical unit with a complaint of a lump on the left side of his neck, just below his ear, that has been there for about a week. Finn noticed a small bump on his neck one night about a week ago, which became larger the following day. At that time, he felt like he had a fever, but did not ask to see the nurse because he wanted to go to his “work” at the barn. He said he had a “rash,” but it went away. He also said he had a sore throat at one point in time after he noticed the lump, but it is gone. He does complain of a headache today. He was given Tylenol last night for his headache with little effect, and placed on the Nurse Sick Call list for today, He reports continued headache today. He enjoys his work detail in the barn, especially because there is a new litter of kittens born about 4 weeks ago.
The patient’s Review of Systems (ROS) is positive for a slight cough. His ROS is negative for abdominal pain, nausea, vomiting, or diarrhea. There is no eye discharge, pain, or irritation. There are no ear symptoms or nasal symptoms. There are no current skin symptoms, and the skin overlying the lump is not red or draining. Finn has no surgical history, and his only diagnosis on the Problem List is atopic dermatitis, with the latest flare-up about nine months ago.
Allergies: No known drug allergies; no known food allergies.
Medications: Tylenol PRN
OBJECTIVE
Vitals: T 100.4°F; P 77; R 16; BP 113/60; HT 5’6″, [25th percentile]; WT 125 lbs, [25th percentile]; BMI 24.2, 44th percentile.
Physical Examination:
General: Alert and oriented, with obvious swelling on the left jaw line.
Psychiatric: Appropriate interaction for age. Affect is animated and mood is regular.
Skin, Hair, Nails: Scattered superficial abrasions noted on bilateral upper extremities (hands and forearms), which patient states are from playing with the kittens and do not hurt. No abnormal findings with hair or nails.
Eyes: Sclera clear.
ENT/Mouth: Ear canals are unremarkable; tympanic membrane is pearly grey with no redness or bulging noted. Mouth mucosa is pink and moist without redness or exudate.
Neck: Lump noted just under left ear, approximately 3 cm in diameter, firm and tender to palpation.
Lungs: Clear to auscultation bilaterally without adventitious sounds.
Heart: S1S2, RRR without murmur, rubs, or gallops.
Abdomen: Soft, non-tender to palpation, +bowel sounds x4.
Neurologic: No focal deficits.
CORRECTIONAL NURSE ACTIONS
Finn is referred to the provider for an appointment – placed on Provider Sick Call List for today.
Finn is seen by the Provider That day
PROVIDER ACTIONS
Review of Systems
The Subjective information and the ROS obtained by the nurse was reviewed with the patient. No additional information was added.
Provider Physical Examination
General: Alert and oriented x 4, cooperative and engaged in the evaluation.
Psychiatric: Appropriate interaction for age. Affect is animated and mood is regular.
Skin, Hair, Nails: Scattered superficial abrasions, in various stages of healing, noted on bilateral forearms and hands, which patient states are from playing with the new barn kittens and do not hurt. No unexpected findings with hair or nails.
Eyes: Sclerae clear.
ENT/Mouth: Ear canals are patent, and tympanic membranes are pearly grey with good light reflex, no erythema or drainage noted. Mouth mucosa is pink and moist without erythema or exudate.
Neck: Some limit to ROM secondary to a firm, but not hard, mobile 3 cm (diameter) left-sided submandibular mass. The mass is tender to palpation without significant overlying induration or erythema but is slightly warm to the touch. There is no other anterior, occipital, or supraclavicular lymphadenopathy palpated.
Lungs: Clear to auscultation bilaterally without adventitious sounds.
Heart: S1S2 RRR without murmur, rubs, or gallops.
Abdomen: Soft, non-tender to palpation, non-distended, with no organomegaly. Normoactive bowel sounds present in all four quadrants.
Neurologic: No focal deficits. Cranial nerves II to XII are intact.
Differential Diagnoses for FINN
Anterior cervical lymphadenopathy is most commonly reactive and can occur secondary to viral URI, otitis media, sinusitis, EBV infection, abscess, or tinea capitis. This patient did not present with evidence of any other infectious process of the head and neck, so a primary lymphatic process is more likely.
Cervical lymphadenitis which can be caused by staph and strep species.
Malignancy, such as lymphoma, leukemia, rhabdomyosarcoma, or neuroblastoma or metastatic disease from another malignancy, such as nasopharyngeal or thyroid cancer, needs to be considered in any patient who presents with lymphadenopathy. .
Cat scratch disease is caused by Bartonella henselae and is an uncommon, but not rare, cause of lymphadenopathy. It is more associated with young cats and kittens. The absence of a specific scratch or bite should not exclude this disease. The more acute version of CSD may present with fever and is known as cat scratch fever. This diagnosis is congruent with the patient’s history and presentation.
Atypical Kawasaki disease is a consideration for a differential but unlikely. Even though the patient had 5 days of fever and lymphadenopathy, he had none of the other major or minor criteria for Kawasaki disease, making this a less likely diagnosis.
Most Likely Diagnosis: Cat Scratch Disease
The most likely diagnosis is Cat Scratch disease. Given the history playing with the new kittens in the barn and the presence of scratch marks on his arm, cat scratch disease is the most likely diagnosis.
Diagnostic Tests/Imaging
Testing for B. henselae is commonly available by a direct IFA assay, but the test does have cross-reactivity with other infections. Enzyme immunoassays and PCR may be available locally, but the organism typically is very difficult to grow in culture.
In this patient, diagnostic testing was deferred because the testing would take too long to get results to be clinically useful. Presumptive treatment was started with a plan to do further testing if the patient did not improve.
PATHOPHYSIOLOGY
Cat SCratch Disease
Cat Scratch disease is caused by the pleomorphic, gram-negative bacillus Bartonella henselae. The bacteria can be spread from cat to cat by the cat flea Ctenocephalides felis but is only known to be spread to humans by the bite or scratch of a cat. Cats and kittens under 1 year of age are most likely to carry the bacteria. Stray cats may be more likely carriers than domestic cats, but most cases result from domestic cat exposure. Many patients do not know, or recall, a bite or scratch, so the absence of them should not exclude Cat Scratch disease from the differential for a patient presenting with symptoms and a history of being around cats. A papule or pustule may be present at the site of inoculation. The incubation period is 5 to 50 days for lymphadenopathy to appear (median 12 days). The organism may cause long-lasting lymphadenopathy, which will resolve without treatment over 2 to 4 months. The pathogenesis of this lymphadenopathy is not entirely clear. Systemic illness may be seen and neuroretinitis can occur, particularly when the eye is the site of inoculation (which can occur from rubbing the eye with a contaminated hand). Full visual recovery is typical in neuroretinitis due to Cat Scratch disease; however, ophthalmologic evaluation to exclude other pathologies should be done. Immunocompromised patients may have bacillary angiomatosis and bacillary peliosis, so all immunocompromised patients with Cat Scratch disease should be treated. The organism responds to macrolide, tetracycline, and aminoglycoside antibiotics. It does not respond to beta-lactams. No medications are specifically FDA indicated for infection with B. henselae.
PLAN
Azithromycin 500mg po x 1 on day 1, then 250mg po qd for 4 days
Tylenol 650 mg BID PRN for fever, discomfort
Follow-up Provider Sick Call appointment in 1 week
PATIENT EDUCATION
Course of Cat Scratch disease and what to expect.
He can continue to play with the kittens, but be mindful of getting scratched.
Potential adverse effects of the medications to manage fever and antibiotics for the infection
Return to clinic if symptoms worsen or new symptoms appear; otherwise he is scheduled to see the provider in one week.
REFERENCES
AAP Committee on Infectious Diseases Red book. In: Kimberlin DW, Brady MT, Jackson MA, eds. Red Book. 31st ed. Bartonella Henselae (Cat Scratch Disease); 2018.
English R. Cat-scratch disease. Pediatr Rev. April 2006;27(4):123–128. doi:10.1542/pir.27-4-123
Medscape. Azithromycin. https://reference.medscape.com/drug/zithromax-zmax-azithromycin-342523 5.Pfizer Labs. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/050710s039,050711s036,050784s023lbl.pdf
Weinstock MS, Patel NA, Smith LP. Pediatric cervical lymphadenopathy. Pediatr Rev. September 2018;39(9): 433–443. doi:10.1542/pir.2017-0249
Wijesinghe, Sampath. (2021). 101 Primary care case studies: A workbook for clinical and bedside skills, pp. 333-345. Springer Publishing Company. Kindle edition.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.
S. Hayden, BSN, MSN, PhD says
Subjective data should be what the client says: For example – I had a lump and a rash last week and felt like I had a fever. Now I have headaches and the Tylenol “doesn’t work.” Much of what you have in the subjective block most properly belongs in the objective findings. Subjective should not include the nurse’s assessment and ROS
Lori Roscoe says
Hi and thanks for your comments. Actually, the Review of Systems (ROS) is all subjective information from the patient at the time of the assessment and should be in the subjective section of the SOAP(E) note. Perhaps there is confusion because I did not state in each sentence under ROS that “patient reports” or “patient states.” Please accept my apologies! All of the objective findings from the evaluation are listed under Objective.