NUR511 511 MARY SOAP NOTE WEEK 2

Mary, 44, female, caucasian S. CC (chief complaint): Sore throat HPI: Mary, a 44 year old Caucasian female presents with sore throat while in the office with her twin boys. She states the sore throat started yesterday and hurts worse when she swallows. She does not eat or drink related to the pain associated with swallowing. On further questioning Mary reports new onset fatigue and chills. She thought she was just tired from being woken up by her sick kids but now really feels bad. She has not checked her temperature. Reports pain of 4/5 when swallowing. States it feels like something sharp is in her throat when she swallows. States she has not been hoarse or had a cough. No information was provided on any relieving factors or treatment at home. Onset: yesterday Location: throat Duration: no information provided Characteristics: sore throat Aggravating Factors: hurts worse when she swallows Relieving Factors: no information provided Treatment: no information providedSeverity: does not eat or drink related to pain Current Medications: daily multivitamin and a B complex vitamin