I HUMAN CASE STUDY WEEK 3# REBECCA
FIGUEROA 23 YEAR OLD FEMALE 3 REASON
FOR ENCOUNTER FEVER AND SORE THROAT
LATEST 2O25!!! GRADED A
, Patient Summary:
Rebecca Figueroa is a 23-year-old female presenting with a 3-day history of
fever and sore throat. She reports progressive throat pain, particularly with
swallowing, accompanied by fatigue, chills, and mild headache. She denies
cough, nausea, vomiting, or shortness of breath. She has no known sick
contacts or recent travel. She has been self-medicating with acetaminophen,
which provides temporary relief. Her past medical history is unremarkable.
The clinical picture is consistent with an acute upper respiratory tract
infection, possibly viral pharyngitis or streptococcal pharyngitis (strep
throat). Further evaluation, including a physical exam and possibly a rapid
strep test or throat culture, is warranted.
Physical Examination:
• General: Alert and oriented ×3; appears mildly ill but in no acute
distress.
• Vital Signs:
o Temperature: 101.5°F (38.6°C)
o Heart Rate: 96 bpm
o Respiratory Rate: 16 bpm
o Blood Pressure: 118/76 mmHg
o SpO₂: 98% on room air
• HEENT:
o Head: Normocephalic, atraumatic
o Eyes: No conjunctival injection or discharge
o Ears: Tympanic membranes clear, no erythema or effusion
o Nose: Mild congestion, mucosa slightly erythematous
o Throat: Erythematous posterior pharynx with bilateral tonsillar
enlargement and exudates; uvula midline; no petechiae on the
palate
o Neck: Tender bilateral anterior cervical lymphadenopathy; no
neck stiffness or meningismus
FIGUEROA 23 YEAR OLD FEMALE 3 REASON
FOR ENCOUNTER FEVER AND SORE THROAT
LATEST 2O25!!! GRADED A
, Patient Summary:
Rebecca Figueroa is a 23-year-old female presenting with a 3-day history of
fever and sore throat. She reports progressive throat pain, particularly with
swallowing, accompanied by fatigue, chills, and mild headache. She denies
cough, nausea, vomiting, or shortness of breath. She has no known sick
contacts or recent travel. She has been self-medicating with acetaminophen,
which provides temporary relief. Her past medical history is unremarkable.
The clinical picture is consistent with an acute upper respiratory tract
infection, possibly viral pharyngitis or streptococcal pharyngitis (strep
throat). Further evaluation, including a physical exam and possibly a rapid
strep test or throat culture, is warranted.
Physical Examination:
• General: Alert and oriented ×3; appears mildly ill but in no acute
distress.
• Vital Signs:
o Temperature: 101.5°F (38.6°C)
o Heart Rate: 96 bpm
o Respiratory Rate: 16 bpm
o Blood Pressure: 118/76 mmHg
o SpO₂: 98% on room air
• HEENT:
o Head: Normocephalic, atraumatic
o Eyes: No conjunctival injection or discharge
o Ears: Tympanic membranes clear, no erythema or effusion
o Nose: Mild congestion, mucosa slightly erythematous
o Throat: Erythematous posterior pharynx with bilateral tonsillar
enlargement and exudates; uvula midline; no petechiae on the
palate
o Neck: Tender bilateral anterior cervical lymphadenopathy; no
neck stiffness or meningismus
