Exam (elaborations)
I Human Streptococcal Pharyngitis 23-year-old female CC: Acute onset sore throat and headache
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I Human Streptococcal Pharyngitis 23-year-old female CC: Acute onset sore throat and headache
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By: Spashnets • 4 months ago
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Diagnosing and Managing Streptococcal PharyngitisMSN-RN-AGAC, Walden University
NURS6512N-17, Advanced Health Assessment & Diagnostic Reasoning
, Diagnosing and Managing Streptococcal Pharyngitis
Introduction
The patient is a 23-year-old female presenting with an acute onset sore throat and headache.
Upon physical examination, she is found to have a fever of 101.5°F, tender cervical
lymphadenopathy, erythematous pharynx with exudate, uneven enlarged tonsils bilaterally, and
bilateral. Acetaminophen has been effective at reducing her fever and headache, but the pain
from her sore throat still impedes eating with no reduction in appetite. The patient has a known
sick contact of her roommate with an unknown diagnosis.
Past Medical History:
- Childhood mononucleosis
- Up to date on scheduled vaccines with the exception of the most recent annual flu
vaccine
Surgical History:
- no surgical history
Medications:
- drospirenone/ethinyl estradiol (oral contraceptive pill) 3mg/0.02mg tabs: 1tab PO daily
for contraception
Allergies: No known drug allergies. No known environmental, food, or seasonal allergies.
Family History:
Father – Unknown Mother-
living, hypertension Social
History:
The patient is a graduate student, living with her roommate. The patient feels safe and well-cared
for in her home. She denies a history of smoking and recreational drugs. She reports occasional
drinking but only socially, 1-2 beers, 1-2 times per week. The patient is sexually active with one
partner taking her birth control as scheduled.
Review of Systems:
-Skin: Clean, dry, warm, and intact bilaterally with good turgor
-Hematopoietic: Positive for headaches, enlarged tender cervical lymph nodes.
-Head and Face: No pain, traumatic injury, ptosis, loss of sensation.
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