Sore Throat
Married, drinks alcohol socially, denies tobacco or illicit drug use.
difficulty swallowing, denies cough and hoarseness.
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, HEENT: Head: Normocephalic. Hair thick and distribution throughout scalp. Eyes: without
exudate, sclera clear. Contact lenses noted. Ears: Tympanic membranes gray and intact with
cone of light noted. Pinna and tragus non-tender. Nose: Nares patent without exudate. Throat:
Oropharynx moist with erythema with white exudate noted. Tonsils 3/4
bilaterally. Teeth in good repair, no cavities noted. Neck supple. Thyroid midline, small and
firm without palpable masses.
Cardiovascular: S1 S2 noted, no murmurs, palpitations, chest pain or discomfort noted.
Tachycardia.
Respiratory: Respirations even and unlabored, no distress noted. Lung sounds CTA all
anterior and posterior lung fields bilaterally. No SOB, wheezing, or cough observed.
Gastrointestinal: Abdomen soft, non-tender, bowel sounds present all four quadrants. No
organomegaly noted.
Lymphatics: Anterior cervical lymph tender to palpation. No lymphadenopathy.
Diagnostic results: Rapid strep test positive.
A:
Streptococcal Pharyngitis (ICD-10 J02.0): Infectious inflammation of the pharynx and
the pharyngeal tonsils, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Pharyngitis and
tonsillitis usually occur at the same time and these two diseases are contagious. This is caused
by the Group A beta-hemolytic streptococcal infection, which is caused by group A
Streptococcus. This can cause scarlet fever or autoimmune rheumatic fever it not treated with
antibiotics, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). People diagnosed with this
illness must have 2-3 of the following symptoms and if they do the Rapid strep test is performed
and antibiotic therapy started symptoms include fever greater than 100.5, tonsillar exudate,
tender anterior cervical lymphadenopathy, and no cough (Dunphy, Winland-Brown, Porter, &
Thomas, 2015). Mary presents with all these symptoms.
P:
Medications:
Rx: Amoxicillin
Amoxicillin 500 mg capsules
Sig: 1 cap PO BID Disp #20 (twenty), No refills (Epocrates, 2017).
Rx: Acetaminophen
Acetaminophen 325 mg 2 tabs PO every 4-6 hours as needed for pain or fever, (Dunphy,
Winland-Brown, Porter, & Thomas, 2015).
Nonprescription throat lozenges as needed for pain, (Dunphy, Winland-Brown, Porter, &
Thomas, 2015).
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Married, drinks alcohol socially, denies tobacco or illicit drug use.
difficulty swallowing, denies cough and hoarseness.
1|Page
, HEENT: Head: Normocephalic. Hair thick and distribution throughout scalp. Eyes: without
exudate, sclera clear. Contact lenses noted. Ears: Tympanic membranes gray and intact with
cone of light noted. Pinna and tragus non-tender. Nose: Nares patent without exudate. Throat:
Oropharynx moist with erythema with white exudate noted. Tonsils 3/4
bilaterally. Teeth in good repair, no cavities noted. Neck supple. Thyroid midline, small and
firm without palpable masses.
Cardiovascular: S1 S2 noted, no murmurs, palpitations, chest pain or discomfort noted.
Tachycardia.
Respiratory: Respirations even and unlabored, no distress noted. Lung sounds CTA all
anterior and posterior lung fields bilaterally. No SOB, wheezing, or cough observed.
Gastrointestinal: Abdomen soft, non-tender, bowel sounds present all four quadrants. No
organomegaly noted.
Lymphatics: Anterior cervical lymph tender to palpation. No lymphadenopathy.
Diagnostic results: Rapid strep test positive.
A:
Streptococcal Pharyngitis (ICD-10 J02.0): Infectious inflammation of the pharynx and
the pharyngeal tonsils, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Pharyngitis and
tonsillitis usually occur at the same time and these two diseases are contagious. This is caused
by the Group A beta-hemolytic streptococcal infection, which is caused by group A
Streptococcus. This can cause scarlet fever or autoimmune rheumatic fever it not treated with
antibiotics, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). People diagnosed with this
illness must have 2-3 of the following symptoms and if they do the Rapid strep test is performed
and antibiotic therapy started symptoms include fever greater than 100.5, tonsillar exudate,
tender anterior cervical lymphadenopathy, and no cough (Dunphy, Winland-Brown, Porter, &
Thomas, 2015). Mary presents with all these symptoms.
P:
Medications:
Rx: Amoxicillin
Amoxicillin 500 mg capsules
Sig: 1 cap PO BID Disp #20 (twenty), No refills (Epocrates, 2017).
Rx: Acetaminophen
Acetaminophen 325 mg 2 tabs PO every 4-6 hours as needed for pain or fever, (Dunphy,
Winland-Brown, Porter, & Thomas, 2015).
Nonprescription throat lozenges as needed for pain, (Dunphy, Winland-Brown, Porter, &
Thomas, 2015).
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