I HUMAN CASE AMINA JOHNSON 23 Y/O 5'7" (170
CM) 120.0 IB (54.5 KG) REASON FOR ENCOUNTER
FEVER AND SORE THROAT. LOCATION OUT PATIENT
CLINIC WITH X-RAY, ECG AND LABORATORY
CAPABILITIES generated RAY, ECG AND
LABORATORY CAPABILITIES Case Summary
Case Study: Amina Johnson
Patient Information:
• Name: Amina Johnson
• Age: 23 years
• Sex: Female
• Height: 5’7” (170 cm)
• Weight: 120 lbs (54.5 kg)
• Chief Complaint (CC): Fever and sore throat
History of Present Illness (HPI):
Amina Johnson is a 23-year-old female presenting with a 3-day
history of fever and sore throat. The sore throat is severe, worse
with swallowing, and associated with fatigue, body aches, and
mild headache. She reports fever peaking at 102.2°F (39°C),
with chills and sweating. She has also noticed swollen glands in
her neck but denies a cough or nasal congestion.
,No recent travel or sick contacts, but she works as a daycare
teacher, where some children have had recent colds. She denies
nausea, vomiting, difficulty breathing, or rash.
Past Medical History (PMH):
• No chronic illnesses
• No history of tonsillitis or recurrent throat infections
• No history of asthma or allergies
Medications:
• Occasional ibuprofen for pain relief
Allergies:
• No known drug allergies
Family History (FH):
• No family history of autoimmune diseases or
immunodeficiency
• No family history of rheumatic fever
Social History (SH):
• Works as a daycare teacher (frequent exposure to
children)
• Non-smoker, no alcohol or drug use
• Diet: Well-balanced, adequate hydration
• Sexual History: Sexually active, uses barrier protection
, Review of Systems (ROS):
• General: Fever, fatigue, body aches
• HEENT: Severe sore throat, swollen glands, no nasal
congestion, no ear pain
• Respiratory: No cough, shortness of breath, or wheezing
• Gastrointestinal: No nausea, vomiting, or abdominal pain
• Skin: No rash
Physical Examination (PE):
Vital Signs:
• Temperature: 102.2°F (39°C)
• Heart Rate: 100 bpm (mild tachycardia due to fever)
• Respiratory Rate: 16 breaths/min
• Blood Pressure: 110/70 mmHg
• Oxygen Saturation: 98% on room air
General Appearance:
• Alert, appears tired but in no acute distress
Head, Eyes, Ears, Nose, Throat (HEENT):
• Throat:
o Erythematous pharynx with bilateral tonsillar
swelling
o White exudates on tonsils
o No trismus or difficulty opening mouth (rules out
peritonsillar abscess)
o No stridor or drooling (rules out epiglottitis)
CM) 120.0 IB (54.5 KG) REASON FOR ENCOUNTER
FEVER AND SORE THROAT. LOCATION OUT PATIENT
CLINIC WITH X-RAY, ECG AND LABORATORY
CAPABILITIES generated RAY, ECG AND
LABORATORY CAPABILITIES Case Summary
Case Study: Amina Johnson
Patient Information:
• Name: Amina Johnson
• Age: 23 years
• Sex: Female
• Height: 5’7” (170 cm)
• Weight: 120 lbs (54.5 kg)
• Chief Complaint (CC): Fever and sore throat
History of Present Illness (HPI):
Amina Johnson is a 23-year-old female presenting with a 3-day
history of fever and sore throat. The sore throat is severe, worse
with swallowing, and associated with fatigue, body aches, and
mild headache. She reports fever peaking at 102.2°F (39°C),
with chills and sweating. She has also noticed swollen glands in
her neck but denies a cough or nasal congestion.
,No recent travel or sick contacts, but she works as a daycare
teacher, where some children have had recent colds. She denies
nausea, vomiting, difficulty breathing, or rash.
Past Medical History (PMH):
• No chronic illnesses
• No history of tonsillitis or recurrent throat infections
• No history of asthma or allergies
Medications:
• Occasional ibuprofen for pain relief
Allergies:
• No known drug allergies
Family History (FH):
• No family history of autoimmune diseases or
immunodeficiency
• No family history of rheumatic fever
Social History (SH):
• Works as a daycare teacher (frequent exposure to
children)
• Non-smoker, no alcohol or drug use
• Diet: Well-balanced, adequate hydration
• Sexual History: Sexually active, uses barrier protection
, Review of Systems (ROS):
• General: Fever, fatigue, body aches
• HEENT: Severe sore throat, swollen glands, no nasal
congestion, no ear pain
• Respiratory: No cough, shortness of breath, or wheezing
• Gastrointestinal: No nausea, vomiting, or abdominal pain
• Skin: No rash
Physical Examination (PE):
Vital Signs:
• Temperature: 102.2°F (39°C)
• Heart Rate: 100 bpm (mild tachycardia due to fever)
• Respiratory Rate: 16 breaths/min
• Blood Pressure: 110/70 mmHg
• Oxygen Saturation: 98% on room air
General Appearance:
• Alert, appears tired but in no acute distress
Head, Eyes, Ears, Nose, Throat (HEENT):
• Throat:
o Erythematous pharynx with bilateral tonsillar
swelling
o White exudates on tonsils
o No trismus or difficulty opening mouth (rules out
peritonsillar abscess)
o No stridor or drooling (rules out epiglottitis)
