i-human Amanda wheaton case updated
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 complain...
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
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