i-human Amanda wheaton .

Are your immunizations up to date. Reason for encounter: “i have a really bad sore throat” HPI: The patient is a 23-year-old female who presents to the clinic with a sore throat and a fever of 101.5 that began two days ago. She also complains of a headache that comes and goes as well as swollen and tender b/l glands on her neck. She reported that her sore throat began suddenly two days ago. She reports that he sore throat pain is constant but her headaches and fever comes and goes. She describes her sore throat as an ice pick in her throat and rates her pain as an 11 on a scale of 1-10. Tylenol appears to alleviate her sore throat, fever and headaches; ice cream appears to alleviate her sore throat and swollen glands. The patient reports that she has not received her influenza vaccine but is up to date on all other immunizations. She also states that she is in a monogamous relationship where she occasionally performs and receives oral intercourse. The patient reports that her roommate had a bad sore throat earlier in the week; however, she is unaware of what her diagnosis was. ROS: General: denies weight loss, malaise, chills, or night sweats. Pt is currently febrile. Patient is a good historian for her health hx HEENT/ Neck : head: occasional headaches; denies any head trauma eyes: denies eye pain, redness, or discharge ears: denies ear pain or discharge Nose: denies nasal congestion throat: sore throat that is an 11/10 severity with an ice pick characteristic. Pt c/o dysphagia neck: swollen b/l glands Cardiovascular: negative Respiratory: denies cough or difficulty breathing Gastrointestinal: negative Genitourinary: negative Musculoskeletal/ Osteopathic structural examination: negative Neurologic : negative Integumentary/ breast: negative Psychiatric: negative Endocrine: This study source was downloaded by from CourseH on :31:26 GMT -05:00 Hematologic/ lymphatic : Allergic/ immunologic : Past medical hx: Hospitalizations/ surgery: Preventative health : up to date with all immunizations except influenza vaccine Medications: OTC Tylenol and taking BC as prescribed Allergies: no NKDA; NKFA Social hx: The patient reports she is in a monogamous relationship where she occasionally performs and receives oral intercourse. The patient reports that her roommate had a bad sore throat earlier in the week; however, she is unaware of what her diagnosis was. Family hx: Physical exam: General: the patient is AxOx4. She appears well-groomed and appropriately dressed. Her speech is clear and follows a logical sequence. She does not appear to be in any distress; her skin is pink, warm, and intact. HEENT/Neck: Head: normocephalic, atraumatic. Scalp and temporal arteries are non-tender. Eyes: PERRLA, EOMI. No ptosis or periorbital edema present Throat: tonsils are mildly to moderately enlarged; prominent exudates bilaterally; Posterior pharyngeal erythema present; no oral ulcers present Neck: no decreased ROM; trachea is midline and freely movable; there is tender b/l cervical lymphadenopathy; nodes are ~ 1.5 cm in size; rubbery and mobile Cardiovascular: normal heart rate with normal rhythm. No heaves, thrills, or bruits. PMI location at the 5th intercostal space mid-clavicular line