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NURS 6512 case study 2: focused throat exam

Two details in the stem argue against the diagnosis everyone writes. Lily has a runny nose and a hoarse voice, and both of those make strep less likely, not more.

Aug 6, 2026Updated Aug 10, 2026

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Last reviewed · August 6, 2026

Written by

Aaron Bishop

MA, Education

assignment interpretation and research-methods coaching across disciplines

Reviewed by

Dr. Nathan Cole

PhD, Rhetoric & Composition

Argumentation and thesis development

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Interpret the task
Assignment instructions
Deliverables
Proposed outline
Research plan
Reference shortlist
Final review

The two details that rule out the obvious answer

The case is built to punish the reflex answer, and it tells you so in the last sentence. Lily is 20, has had a sore throat for three days, and there is an outbreak of flu-like illness on her campus — which pulls hard toward streptococcal pharyngitis. Then the stem adds that she has a runny nose and a slight hoarseness in her voice. Both of those are viral features, and both reduce the likelihood of group A strep rather than supporting it. One study cited in the current literature found that patients presenting with three viral symptoms tested positive for strep only 23.2% of the time. A SOAP note whose primary diagnosis is strep has read the setting and not the findings. That does not mean strep is off the list. It means the ranking has to be argued rather than assumed, and that a formal score belongs in your assessment instead of an impression.

Notice what the phrase "but doesn't sound congested" is doing, because it is the most deliberately placed clause in the stem. Rhinorrhoea with congestion points one way — an upper respiratory infection or sinus involvement with obstruction. Rhinorrhoea without congestion, combined with hoarseness, points at the larynx and pharynx rather than the sinuses. Assignment stems in this course are written tightly enough that a negative finding is never filler; it is there to close a branch of your differential. Your HPI should record it and your assessment should use it, because an examiner who wrote that clause is looking to see whether anybody noticed. The same applies to what the stem withholds. You are told nothing about fever, tonsillar exudate, cervical nodes or the state of her spleen, and each of those is a discriminator you would need — so the history and exam sections should show you going after them rather than quietly inventing values.

So build the differential from the findings rather than from the campus outbreak. The assignment asks for at least five conditions with justification for each, and this presentation supports six comfortably:

Condition	What in Lily's presentation supports it	What argues against, or what would settle it
Viral pharyngitis	Rhinorrhoea, hoarseness, three-day course, community outbreak, absence of congestion	The most likely diagnosis and therefore the one needing the most careful justification, not the least
Infectious mononucleosis	Age 20 on a college campus, sore throat, decreased appetite, headache — the demographic the condition is defined by	Needs posterior cervical nodes, splenomegaly and atypical lymphocytes; heterophile testing is 63–84% sensitive and worse early, so a negative in week one does not exclude it
Group A streptococcal pharyngitis	Odynophagia, headache, decreased appetite, a described outbreak	Rhinorrhoea and hoarseness both count against it. Score her formally rather than asserting low risk
Influenza	The stem literally says flu-like symptoms are sweeping the campus over two weeks	Sore throat predominating over fever, myalgia and abrupt onset argues against; ask about the onset pattern
Acute laryngitis	Hoarseness is the presenting feature that most differentiates this case from a routine sore throat	Usually follows a viral URI; ask about voice use, duration, and whether the hoarseness preceded or followed the sore throat
Allergic rhinitis with post-nasal drip	Clear rhinorrhoea without congestion, throat irritation	Seasonality, itch, prior history and absence of systemic symptoms; the three-day onset and outbreak context argue against

Mononucleosis deserves more attention than most notes give it, because two of its management consequences are the reason the diagnosis matters rather than being merely interesting. First, amoxicillin or ampicillin produces a characteristic maculopapular rash in up to 30% of people with mononucleosis — so treating an unconfirmed sore throat empirically as strep in exactly this demographic has a one-in-three chance of producing a rash that will then be recorded as a penicillin allergy for life. Second, splenic rupture occurs in 0.1% to 0.2% of cases, most within the first 21 days, and the guidance is to avoid strenuous activity for three weeks and contact sports for four. Both facts point the same way clinically: confirm before you treat, and if you cannot confirm, say what you would restrict and for how long. That is a more defensible position than empiric antibiotics in a demographic where the commonest cause is viral.

The assignment asks you to "provide evidence from the literature to support diagnostic tests", which means test characteristics rather than test names. For a rapid antigen strep test in adults, pooled immunochromatographic performance is around 91% sensitivity (95% CI 87–94) and 93% specificity (95% CI 92–95). That is the number that justifies acting on a positive and makes a negative reasonably reassuring in an adult — and it is why the guideline does not recommend backup culture for adults after a negative rapid test, given the lower prevalence and the much reduced risk of non-suppurative complications in this age group. For mononucleosis, EBV-specific antibody testing runs around 97% sensitivity and 94% specificity against a heterophile test's 63–84%. Report the confidence intervals as well as the point estimates when you cite them, because the assignment is asking for evidence and an interval is what distinguishes a figure you looked up from one you remembered.

On the note itself, three template requirements catch people out. The review of systems has to be documented across systems, not only the ones you find abnormal, because the template's structure treats pertinent negatives as data. The physical exam section forbids "WNL" and "normal" outright and demands description — what you see, hear and feel — which for a focused throat exam means the pharynx, tonsils, palate, cervical chains and the quality of the voice, described. And the P section is explicitly not required for NURS 6512, so writing a treatment plan is effort spent outside the rubric while the differential justification is what carries the marks. Read the template's own instructions as rubric text rather than as boilerplate — it tells you to paint a picture of what is wrong with the patient, and that phrase is a fair summary of what separates a documented note from a completed form.

One last framing point. The assignment separates "what history would be necessary to collect" from the note, then asks you to write the note as though the history has been taken. Resolve that by writing the HPI to the LOCATES structure with the elements the stem does not supply marked as questions you would ask — exposure and contacts, immunisation status, sexual history given the differential includes gonococcal and acute HIV presentations, prior episodes, and what she has already taken. That way the note reads as a clinical document and still demonstrates the reasoning the earlier bullet asked for. Note as well that the assignment says you were assigned this case by the instructor, so the note should read as a document about Lily specifically rather than as a template with her details substituted into it.

Likely learning objectives

Inferred from the brief — check these against your own rubric.

01
Weigh clinical features against a decision rule rather than against the epidemiological context alone.
02
Recognise a deliberately placed negative finding as a discriminator rather than as filler.
03
Justify diagnostic tests with published performance characteristics rather than by naming them.
04
Identify the management consequences that make a differential diagnosis matter clinically.
05
Complete an Episodic/Focused SOAP note to its template's documentation standards.

Assignment instructionsQuoted verbatim

Read the full question

Review every instruction before using the planning guidance that follows.

CASE STUDY 2: Focused Throat Exam Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks, Lily figured she shouldn’t take her 3-day sore throat lightly. Your clinic has treated a few cases similar to Lily’s. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn’t sound congested. To Prepare · By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor. · Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case. With regard to the case study you were assigned: · Review this week’s Learning Resources and consider the insights they provide. · Consider what history would be necessary to collect from the patient. Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? · Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. Focused Throat Exam Assignment The Assignment Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each. Episodic/Focused SOAP Note Template – (delete information on this template and input one related to the patient in the case study above). Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Location: head Onset: 3 days ago Character: pounding, pressure around the eyes and temples Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia Timing: after being on the computer all day at work Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better Severity: 7/10 pain scale Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance). PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system. Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Focused Throat Exam Assignment ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: No weight loss, fever, chills, weakness or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis. O. Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc. Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines) A. Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines. P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. References You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

Turn the brief into deliverables

01
An Episodic/Focused SOAP note on the assigned case, using the provided template.
02
Evidence from the literature supporting the diagnostic tests appropriate for the case.
03
At least five possible conditions in the differential diagnosis.
04
A justification for the selection of each condition.
05
At least three evidence-based peer-reviewed journal articles or evidence-based guidelines, in APA format.

Working the SOAP template on this case

Patient information and chief complaint

Open the template correctly, with the complaint in Lily's own words.

HPI to the LOCATES structure

Build the symptom analysis, including the elements the stem does not supply as questions you would ask.

Review of systems

Document across systems so pertinent negatives are on the record.

Focused physical examination

Describe the pharynx, tonsils, palate, cervical chains and voice quality in observational language.

Diagnostics with their evidence

Name the tests you would order and justify each with published performance data or a guideline.

Differential diagnoses, ranked and justified

Give at least five conditions, primary first, each tied to a specific feature of this presentation.

Finding evidence for the tests, not just their names

Recommended databases

PubMed and PubMed Central
NCBI Bookshelf (StatPearls)
IDSA clinical practice guidelines
CINAHL

Search sequence

1.
Search for the clinical decision rule by name — Centor or McIsaac — rather than for 'sore throat diagnosis', so you get the scoring and its validation rather than patient education material.
2.
Look specifically for which features argue against streptococcal infection. The presence of viral features is the discriminating evidence in this case, and it is easier to find framed as a negative predictor than as a differential.
3.
For test justification, search the test name plus 'sensitivity specificity meta-analysis' and record the adult subgroup figures, since adult and paediatric performance differ and your patient is 20.
4.
For mononucleosis, search the management consequences rather than the presentation: the aminopenicillin rash and the splenic rupture risk are what make the diagnosis actionable and both carry citable figures.
5.
Check the currency of any guideline you cite for pharyngitis, and note that recommendations differ between adults and children on backup culture after a negative rapid test.

Reference shortlist

These are authoritative starting points, not a ready-made bibliography. A qualified reviewer must confirm that each source fits the assignment and supports the claim beside which it is cited.

Nothing here is cleared for citation until you have read it.

01
Streptococcal Pharyngitis
StatPearls Publishing (NCBI Bookshelf) · 2025
The claim the whole case turns on: 'Symptoms of viral illness, like cough, rhinorrhea, or hoarseness, reduce the likelihood of streptococcal pharyngitis but cannot rule it out', with a 2020 finding that patients presenting with three viral symptoms tested positive only 23.2% of the time. Lily has two of the three named features. Also supplies the differential for a young adult sore throat, including COVID-19, acute HIV, EBV, gonorrhoea, syphilis and Lemierre's syndrome alongside the non-infectious causes.
02
Mononucleosis
StatPearls Publishing (NCBI Bookshelf) · 2026
Why mononucleosis is the differential with consequences attached: amoxicillin and ampicillin produce a characteristic maculopapular rash in up to 30% of those with the condition, splenic rupture occurs in 0.1% to 0.2% of cases with most within the first 21 days, and the advice is to avoid strenuous activity for three weeks and contact sports for four. Also the test characteristics that stop a negative monospot being read as exclusion: heterophile sensitivity 63–84% and specificity 84–100%, against EBV-specific antibody testing at roughly 97% and 94%.
03
Rapid Antigen Group A Streptococcus Test to Diagnose Pharyngitis: A Systematic Review and Meta-Analysis
PLoS One · 2014
The evidence that turns 'I would order a rapid strep test' into a justified diagnostic decision. Across 59 studies and 55,766 patients, immunochromatographic rapid antigen tests in adults pooled at 91% sensitivity (95% CI 87–94) and 93% specificity (95% CI 92–95) — notably better behaved in adults than in children, where heterogeneity was substantial. Lily is 20, so the adult subgroup is the relevant one.

Before you submit

Common mistakes

Making group A strep the primary diagnosis because the campus has an outbreak. Rhinorrhoea and hoarseness both reduce the likelihood of strep, and the stem gives Lily both. The epidemiology raises your prior; the findings lower it, and the findings are more specific.
Ignoring 'but doesn't sound congested'. A negative finding placed that deliberately is closing a branch of the differential. Record it in the HPI and use it in the assessment.
Naming diagnostic tests without their performance. The assignment asks for evidence supporting the tests. 'Rapid strep test' is a name; 91% sensitivity and 93% specificity in adults is a justification for acting on the result.
Listing mononucleosis and moving on. Its consequences are the point: amoxicillin or ampicillin causes a rash in up to 30% of those with mono, and splenic rupture occurs in 0.1–0.2% of cases with activity restriction for three to four weeks.
Treating a negative monospot as exclusion. Heterophile sensitivity is 63–84% and lower early in the illness. In a three-day history a negative result is close to uninformative, and EBV-specific serology is the more sensitive test.
Writing a treatment plan. The template says the P section is not required for NURS 6512. Those words earn nothing while the differential justifications, which do carry marks, go thin.
Documenting the exam with 'WNL' or 'normal'. The template forbids both by name and asks for description of what you see, hear and feel.
Confining the review of systems to abnormal findings. Pertinent negatives are data in this format, and the template expects the systems to be worked through.
Producing exactly five differentials with one line each. The instruction is a minimum with a justification requirement attached, and the justification is where the reasoning is visible.

Submission checklist

The note uses the Episodic/Focused SOAP template, not narrative format.
The HPI follows LOCATES and opens with age, race and gender.
The chief complaint is in the patient's own words and brief.
Rhinorrhoea, hoarseness and the absence of congestion all appear and are used in the assessment.
Five or more differentials, each with a specific supporting feature from this case.
The primary or presumptive diagnosis is at the top of the differential list.
Each diagnostic test is supported by cited performance data or a guideline.
The review of systems covers systems beyond the abnormal ones.
No use of 'WNL' or 'normal' in the physical exam section.
No treatment plan written under P, which this course does not require.
At least three peer-reviewed articles or evidence-based guidelines, APA formatted.

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