02 Dec EE, a 20-year-old male college student, presents to the clinician during the spring season with a 4-day history of fever, sore throat, body aches, and headache.
EE, a 20-year-old male college student, presents to the clinician during the spring season with a 4-day history of fever, sore throat, body aches, and headache. EE has been resting and drinking plenty of fluids. Ibuprofen has reduced his fever slightly. About 4 weeks ago, EE went on a spring break trip to Florida, where he had unprotected sex with a new female partner. He also tried IV heroin for the first time.
Medications
- Ibuprofen 600 mg every 6 hours as needed for fever
Past Medical History
- Tonsillectomy, age 10
- Chlamydia, age 18
- Up to date on immunizations
Family History
- Noncontributory
Social History
- Drinks 2 to 3 beers Friday and Saturday nights since age 18
- Sexually active with men and women, four sexual partners in the last year
Physical Examination
- EE appears anxious
- Body mass index: 22; blood pressure: 128/76; pulse: 88; respiration rate: 18; temperature: 102.7 °F
- Headache, sore throat, fatigue, myalgias
- Skin: warm, slightly moist without rashes or lesions
- Ears, nose, throat, mouth: scant rhinorrhea and mild edema and erythema of the upper palate and posterior oropharynx
- Neck: diffuse shotty anterior cervical adenopathy
- Cardiovascular: normal S1, S2, regular rate and rhythm without murmur or gallop
- Examination of the abdomen, neurological, and musculoskeletal systems are within normal limits
Labs and Imaging
- Fourth-generation HIV test: p24 positive, H1V1 positive
- Computed tomography angiogram (CTA): good air movement and no distress
- In addition to HIV, what other differential diagnoses should be considered in a patient with this presentation?
- What further diagnostic evaluation should be completed for EE?
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