History:
Date & time: 07/03/23 10:00 am
Full Name: AA
DOB: XXX
Address: Jamaica, NY
Age: 21 y/o
Sex: female
Race: African American
Religion: Christian
Source: Patient herself
Transportation: herself
Reliability: Reliable
Location: Ozone Park, NY
Chief Complaint: “My throat hurts” x 4 days
History of Present Illness:
21 y/o female with no significant past medical history presents today complaining of a sore throat for the past 4 days. Pt states that she has tried Tylenol and ibuprofen to help her symptoms, but it has not worked. Pt also states that swallowing makes her pain worse, but she is still able to eat and drink, and that the severity of her pain is 6/10. Pt also reports that she has felt “feverish” but does not have a thermometer at home therefore has not taken her temperature. She states that she is currently only sexually active with her boyfriend however they do participate in unprotected oral sex, and she has never had vaginal intercourse. Pt denies cough, vomiting, nausea, diarrhea, abdominal pain, sick contacts, recent travel, rash, headache, ear pain, myalgias, and h/o STDs.
Past Medical History:
- No PMH
- Immunizations up to date; flu vaccine yearly (unknown date); Covid vaccines and booster up to date (unknown dates).
Past Surgical History:
- No past surgical history.
- No previous blood transfusions.
Medications:
- Denies use of any prescribed medications.
- Denies use of herbal supplements.
Allergies:
- NKDA
- Denies seasonal, food, and animal allergies.
Family History:
- Mother – age 43 alive and well
- Father – age 45 alive and well
- Maternal/paternal grandparents – deceased at unknown age & unknown reasons.
Social History:
- Habits- Pt. denies h/o of smoking or tobacco use along with illicit drug use. Pt. also denies alcohol and caffeine use.
- Travel- Pt. denies any recent travel.
- Marital history- Pt denies ever being married.
- Sexual history- Pt states that she has only participated in oral sex with her boyfriend, has never had any other partners, and has never had vaginal intercourse. Pt also denies h/o any previous STDs.
- Occupational history- Pt attends college.
- Home situation- Lives in campus housing.
- Diet- Pt. states that her diet consists mainly of vegetables, protein, and rice.
- Safety measures– Admits to seatbelt use.
Review of Systems:
General – Pt reports subjective fever. Denies night sweats, weight loss or gain, generalized fatigue, chills, changes in appetite.
Skin, hair, nails –Denies rash, excessive dryness, pigmentations, moles, pruritus, excessive sweating, or changes in hair distribution,
Head – Denies headaches, vertigo, or head trauma, dizziness.
Eyes – Denies glasses or contact usage, Last eye exam 2021 visual acuity unknown. Denies glasses or contact usage, visual disturbances, photophobia, lacrimation, or pruritus.
Ears – Denies deafness, pain, discharge, tinnitus.
Nose/sinuses –Denies discharge obstruction, or epistaxis.
Mouth/throat – Reports sore throat. Last dental exam February 2022. Denies bleeding gums, sore tongue, mouth ulcers, or voice changes.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast – Denies lumps, nipple discharge, or pain.
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Denies palpitations, chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal system – Has regular bowel movements daily. Denies intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.
Nervous – Denies migraines, seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, changes in cognition / mental status / memory, or weakness.
Musculoskeletal system –Denies muscle/joint pain, deformity or swelling, or redness.
Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
Hematological system –Denies anemia, lymph node enlargement, blood transfusions, or history of DVT/PE.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.
Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.
Physical:
General: Thin female, neatly groomed, looks younger than her stated age of 21 years.
Vital Signs: BP: R L
Seated 114/73 N/A
R: 15/min, unlabored P: 79 beats/min, regular
T: 101.4 degrees F (oral) O2 Sat: 98% Room air
Height: 65-inches Weight: 120 lbs BMI: 20.0
Skin: Nonicteric, no scars or rash visualized.
Nose: Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.
Sinuses: Non tender to palpation and percussion over bilateral frontal, ethmoid, and maxillary sinuses.
Ears: Symmetrical and appropriate in size. No lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM pearly grey / intact with light reflex in good position.
Lips – Pink, moist; no cyanosis or lesions.
Mucosa – Pink; well hydrated. No masses: lesions noted. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars.
Teeth – Good dentition / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.
Tongue –no masses, lesions, or deviation.
Oropharynx – Tonsils appear swollen and erythematous with exudates present. Well hydrated; no injection, masses, lesions, or foreign bodies. Uvula midline, pink, no edema or lesions.
Neck – Mild cervical lymphadenopathy present. Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted.
Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.
Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink.
Chest: Symmetrical, no deformities, no trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. non-tender to palpation throughout.
Lungs: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No adventitious sounds.
Heart: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Breasts: exam not done.
Abdomen: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly appreciated.
Female genitalia: exam not done.
Anus, Rectum: exam not done.
Differential diagnosis:
- Strep pharyngitis: Pt presents with fever, sore throat, cervical lymphadenopathy, tonsillar swelling, and exudates. Pt is between 15-44 years of age, has exudates and tonsillar swelling, has swollen cervical lymph nodes, and has a temperature over 100.4 which gives her 4 points according to the Centor criteria. Would do a rapid strep test and a throat culture if it came back positive. I would prescribe either penicillin or amoxicillin to treat the infection and advise the patient to follow up if symptoms worsen or do not improve in the next 5 days.
- Mononucleosis: Pt presents with fever and a sore throat. Pt can also be considered high risk for developing mono due to her being in college. Would get a rapid mono spot to confirm. If it comes back positive would advise the patient to treat symptomatically with Tylenol and Ibuprofen. I would also advise the patient to stay away from contact sports or strenuous activity to decrease the chances of splenic rupture.
- N. gonorrhoeae induced pharyngitis: Pt presents with fever, sore throat, cervical lymphadenopathy, tonsillar swelling, and exudates. Pt also states that she participates in unprotected oral sex. Would order a Nucleic acid amplification test of a pharyngeal swab to confirm the diagnosis. If the test came back positive would treat the patient with a single dose of Ceftriaxone 500mg IM. I would also inform the patient to reach out to her boyfriend and advise him to get treated too as well as anyone else she may have been in sexual contact with.
- Viral infection: Pt is presenting with fever and sore throat. Even though with influenza you would expect to see more symptoms indicating a viral infection influenza needs to be ruled out in this age group and during this season. I would order a rapid flu test and if it came back positive would advise symptomatic treatment with Tylenol.
Assessment: 21 y/o female presents to clinic ℅ of sore throat, fever for the past 4 days.
Work up
- Rapid Covid test- negative
- Rapid mono spot- negative
- Rapid strep test- positive
- Throat culture- pending
- NAAT of throat- pending
- Viral respiratory panel- pending
Plan:
- Prescribe Amoxicillin 500 mg BID for 10 days.
- Advise the patient to take Tylenol to help with fever.
- Observe the patient to see if fever goes down and see if the patient can drink and eat.
- Advise the patient to return if her symptoms worsen or do not improve.
- Strongly recommended the patient to purchase a thermometer off amazon to monitor her temperature.
- ER precautions: if her sore throat worsens to the point where she cannot tolerate foods and/or liquids or if her temperature increases and remains elevated despite administration of Tylenol.
- If the NAAT of the throat comes back positive will reach out to the patient and advise her to return to the office for the appropriate treatment.
- I would also educate the importance of hand hygiene to prevent spreading this on to others.
