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 100000883084650 from CourseHero.com on 03-25-2024 00:21:51 GMT -05:00
https://www.coursehero.com/file/157987839/i-human-Amanda-wheaton-docx/
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 100000883084650 from CourseHero.com on 03-25-2024 00:21:51 GMT -05:00
https://www.coursehero.com/file/157987839/i-human-Amanda-wheaton-docx/
