Student Name: Alixandra Messer
Course: MSN 650
Today’s date: 4/2/2026
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Demographics:
Patient initials: SF
Age: 47 years old
Gender: Male
Pronouns: He/him
Visit Date: 3/31/26
Clinical Location: Triad Health Systems
SUBJECTIVE:
Chief Complaint: “My throat is sore.”
Source & Reliability of History: Patient. Reliability: Reliable
HPI: SF presents with a 3-day history (onset) of sore throat (location). Pain is constant (duration), and SF describes the
pain as sharp (character). Eating or drinking makes the pain worse, and throat lozenges have provided some relief in the
throat (aggravating/relieving). SF rates the pain 4/10. SF also reports a dry cough. SF denies fever, nasal drainage, nasal
congestion, and ear pain. SF denies nausea and vomiting (Pertinent associated symptoms). SF does report a recent
exposure to a coworker with strep.
Any additional narrative:
PMH: Hypertension
PSH: (Surgical history): Appendectomy (2010)
Family History:
Mother: Hypertension (Living)
Father: Hypertension (Living)
Maternal Grandmother: Hyperlipidemia (deceased)
Maternal Grandfather: Type 2 diabetes (Deceased)
, Brother: Hypertension (Living)
Social determinants of health:
Tobacco: Denies any tobacco use in the past or current.
Alcohol: Occasional alcohol use on holidays with family. 1-2 beers.
Illicit drug: Denies any illicit drug use in the past or present.
Environmental exposures: None
Safety Assessment: Depression Screening PHQ9: N/A
Reports feeling safe at home: Yes
Living situation: Currently living in house with spouse.
Vaccinations/Immunizations:
Childhood immunization complete
Influenza Vaccine: Up to date (10/1/2025)
Covid: Up to date (10/1/2025)
Tdap: Up to date (11/5/2024)
Occupation: Lineman
For Children: N/A
For Infants: N/A
For children: N/A
For Teens: N/A
Medications:
Lisinopril 10mg, take 1 tablet daily (Hypertension)
Screenings: Last colonoscopy 5/2025
Allergies and reactions: No known drug allergies.
ROS:
Constitutional: Denies fever, fatigue, chills, weight loss or night sweats.
Dermatologic: Denies rashes, itching, lesions or skin discoloration or changes.
HEENT:
Course: MSN 650
Today’s date: 4/2/2026
======================================================================================
Demographics:
Patient initials: SF
Age: 47 years old
Gender: Male
Pronouns: He/him
Visit Date: 3/31/26
Clinical Location: Triad Health Systems
SUBJECTIVE:
Chief Complaint: “My throat is sore.”
Source & Reliability of History: Patient. Reliability: Reliable
HPI: SF presents with a 3-day history (onset) of sore throat (location). Pain is constant (duration), and SF describes the
pain as sharp (character). Eating or drinking makes the pain worse, and throat lozenges have provided some relief in the
throat (aggravating/relieving). SF rates the pain 4/10. SF also reports a dry cough. SF denies fever, nasal drainage, nasal
congestion, and ear pain. SF denies nausea and vomiting (Pertinent associated symptoms). SF does report a recent
exposure to a coworker with strep.
Any additional narrative:
PMH: Hypertension
PSH: (Surgical history): Appendectomy (2010)
Family History:
Mother: Hypertension (Living)
Father: Hypertension (Living)
Maternal Grandmother: Hyperlipidemia (deceased)
Maternal Grandfather: Type 2 diabetes (Deceased)
, Brother: Hypertension (Living)
Social determinants of health:
Tobacco: Denies any tobacco use in the past or current.
Alcohol: Occasional alcohol use on holidays with family. 1-2 beers.
Illicit drug: Denies any illicit drug use in the past or present.
Environmental exposures: None
Safety Assessment: Depression Screening PHQ9: N/A
Reports feeling safe at home: Yes
Living situation: Currently living in house with spouse.
Vaccinations/Immunizations:
Childhood immunization complete
Influenza Vaccine: Up to date (10/1/2025)
Covid: Up to date (10/1/2025)
Tdap: Up to date (11/5/2024)
Occupation: Lineman
For Children: N/A
For Infants: N/A
For children: N/A
For Teens: N/A
Medications:
Lisinopril 10mg, take 1 tablet daily (Hypertension)
Screenings: Last colonoscopy 5/2025
Allergies and reactions: No known drug allergies.
ROS:
Constitutional: Denies fever, fatigue, chills, weight loss or night sweats.
Dermatologic: Denies rashes, itching, lesions or skin discoloration or changes.
HEENT:
