I HUMAN CASE STUDY WEEK #3 23 YEAR OLD
PATIENT REBECCA FIGUEROA, REASON FOR
ENCOUNTER FEVER AND SORE THROAT . I HUMAN
CASE WALDEN UNIVERSITY
Chief Complaint (CC):
"I have a sore throat and a fever."
???? History of Present Illness (HPI):
Onset: Began 3 days ago
Duration: Constant since onset
Character:
Throat pain, worse with swallowing
Scratchy, raw throat sensation
Associated Symptoms:
,Fever (to 102°F)
Fatigue
Mild headache
Swollen neck glands
Negative Symptoms (ROS relevant negatives):
No cough
No congestion or rhinorrhea
No shortness of breath
No rash
Aggravating Factors: Swallowing, talking
Relieving Factors: None significant
Severity: Moderate to severe throat pain
???? Past Medical History (PMH):
Generally healthy
No chronic illnesses
???? Surgical History:
None
???? Medications:
PRN ibuprofen for pain/fever
???? Allergies:
No known drug allergies (NKDA)
, ???? Family History:
Non-contributory; no significant illnesses reported
???? Social History:
College student
Lives in dormitory
Non-smoker
Occasional alcohol use
No recreational drug use
No recent travel
???? Review of Systems (focused):
Constitutional: Fever, fatigue
HEENT: Sore throat, difficulty swallowing
Respiratory: Denies cough or shortness of breath
GI: Denies nausea, vomiting, or abdominal pain
Skin: No rash
Neuro: Mild headache
Differential Diagnoses (based on HPI):
Group A Streptococcal Pharyngitis
Viral Pharyngitis (e.g., EBV/Mono)
Infectious Mononucleosis
Peritonsillar Abscess (if worsening, muffled voice)
PATIENT REBECCA FIGUEROA, REASON FOR
ENCOUNTER FEVER AND SORE THROAT . I HUMAN
CASE WALDEN UNIVERSITY
Chief Complaint (CC):
"I have a sore throat and a fever."
???? History of Present Illness (HPI):
Onset: Began 3 days ago
Duration: Constant since onset
Character:
Throat pain, worse with swallowing
Scratchy, raw throat sensation
Associated Symptoms:
,Fever (to 102°F)
Fatigue
Mild headache
Swollen neck glands
Negative Symptoms (ROS relevant negatives):
No cough
No congestion or rhinorrhea
No shortness of breath
No rash
Aggravating Factors: Swallowing, talking
Relieving Factors: None significant
Severity: Moderate to severe throat pain
???? Past Medical History (PMH):
Generally healthy
No chronic illnesses
???? Surgical History:
None
???? Medications:
PRN ibuprofen for pain/fever
???? Allergies:
No known drug allergies (NKDA)
, ???? Family History:
Non-contributory; no significant illnesses reported
???? Social History:
College student
Lives in dormitory
Non-smoker
Occasional alcohol use
No recreational drug use
No recent travel
???? Review of Systems (focused):
Constitutional: Fever, fatigue
HEENT: Sore throat, difficulty swallowing
Respiratory: Denies cough or shortness of breath
GI: Denies nausea, vomiting, or abdominal pain
Skin: No rash
Neuro: Mild headache
Differential Diagnoses (based on HPI):
Group A Streptococcal Pharyngitis
Viral Pharyngitis (e.g., EBV/Mono)
Infectious Mononucleosis
Peritonsillar Abscess (if worsening, muffled voice)
