Patient Information:
Initials: Lily Age: 20 years old Sex: Female Race: Caucasian
SUBJECTIVE
CC : “I have had a sore throat for the past three days. Other symptoms include headache, decreased appetite and pain while swallowing”.
HPI: Ms. Lily is a 20-year-old female student presenting a sore throat with additional reduced appetite, headache, and pain while swallowing. She recounts that similar “flu-like” symptom was affecting multiple students at college. Ms. Lily also also has a running and hoarse voice in her voice but did not sound congested. Consequently, she took Tylenol and Chloraseptic lozenges which did little for relief.
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Location: throat
Onset: Three days ago
Character: sore throat
Associated signs and symptoms: headache, pain while swallow, decreased appetite
Exacerbating/Relieving factors: Eyes bothered with light, and Tylenol did not cure the condition.
Severity: 8/10 pain scale
Current Medications: The patient has been taking One-A-Day multivitamins tablet and Blisovi Fe 1/20 a tablet daily.
Allergies: Penicillin
PMHx: No pertinent medical history reported; it is unremarkable. No recent hospitalizations reported in the past. Immunizations are current. The last tetanus shot was taken June 2019 while the last flu shot was taken in September 2018.
Soc Hx. Ms. Lily was born in Galveston, TX, and currently attends college as a full-time student. She is Single and heterosexual. She is in a monogamous relationship with her boyfriend and sexually active. She is a social drinker, takes 1-2 glasses of wine every two weeks. Never smoked and denies the use of illicit/recreational drugs. Drinks green tea daily
Fam Hx:
Maternal Grandmother : died at age 83 related to Stroke
Maternal Grandfather: died at age 98, no health conditions noted
Paternal Grandmother: died at age 38, post-partum hemorrhage
Paternal Grandfather: died at age 102 related to uncontrolled HTN
Mother: age 57, No health conditions reported
Father: age 63, has Arthritis, and HTN
Siblings: She has two sisters, ages 17 and 14. Both are alive and well, no health conditions reported
Review of System:
GENERAL: Patient is alert and awake, and overall appears well
HEENT: Eyes appear normal. No hearing problem or hearing loss. She has complaints of runny nose, sore throat, headaches, and hoarse voice.
SKIN: No itching or rash
CARDIOVASCULAR: No complications, pain or discomfort in the chest
RESPIRATORY: Respirations are regular and unlabored. No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No vomiting, anorexia, nausea, or diarrhea. No reported abdominal pain or blood. Complaints of decreased appetite
GENITOURINARY: No urinary track discomfort and has never been pregnant. Her menses are regular.
NEUROLOGICAL: Reported no cases of syncope, dizziness, ataxia, paralysis, numbness, or tingling. Additionally, there is no change bowel movement or bladder control. Complains of headache that started with the onset of sore throat
MUSCULOSKELETAL: No back, joint or muscle pain
HEMATOLOGIC: No bruising, bleeding or anemia
LYMPHATICS: Swollen nodes in the neck
PSYCHIATRIC: No depression history
ENDOCRINOLOGIC: No report of heat or cold intolerance.No sweating or polyuria
ALLERGIES: Penicillin
OBJECTIVE:
Physical exam: Ht. 5’11’’; Wt.149 lbs; BMI 21.5; Temperature 101.6 Fahrenheit. HEENT: pupil equal and reactive to light. Ears are clear, and the throat has some swelling. Neck exhibits cervical lymphadenopathy. She has a running nose. Skin/Hair/ Nails appear normal.
Diagnostic Results: CMP and CBC ordered. Swab obtained sent to the lab for rapid influenza test, strep test and throat culture test.
ASSESSMENT:
Differential Diagnoses
Influenza: Ms. Lily shows headache, sore throat, and nasal discharge. This could as a result of close-quartered campus setting (National Foundation for Infectious Diseases, 2016)
Diptheria: This condition shows a low-grade fever, headache, sore throat and voice hoarseness (CDC, 2016).This are the same symptoms portrayed by my patient though the condition is unlikely in the U.S. as most people are diagnosed.
Epiglottitis: This condition exhibits vocal changes and sore throats but patients also complain of airway obstruction (Marcin, 2017)
Group A Streptococcal pharyngitis. Lily exhibits sore throat but to ascertain if it is the condition, there is a need to visualize her mouth for possible uvula, exudate and erythematous (Wessels, 2011)
Epstein- Barr virus (EBV) infectious mononucleosis. This condition is spread through a bodily fluid such as saliva and sore throat is the common sign.
References
Centers for Disease Control and Prevention (2016). About Diphtheria. See https://www.cdc.gov/diphtheria/about/index.html
Marcin, J. (2017). Epiglottis. See http://www.healthline.com/health/epiglottitis#overview1
National Foundation for Infectious Diseases (2016). Influenza (Flu). http://www.nfid.org/idinfo/influenza
Wessels, M. R. (2011). Streptococcal pharyngitis. New England Journal of Medicine , 364 (7), 648-655.
