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C.C. Sore throat, fever and sleeping more HPI: J. W. a 16 y.o. M…
C.C. Sore throat, fever and sleeping more
HPI: J. W. a 16 y.o. M presented to the clinic today, he developed a sore throat which began 3 days ago.
J.W. states the pain is described as achy and sharp and is rated 5/10 in terms of intensity. His pain is in
his throat and the pain is associated with swallowing. J.W. states his pain is accompanied by headaches,
decreased appetite, rhinorrhea, and voice hoarseness. He has tried Tylenol with some relief. He has
never felt this bad before.
PMHx: Reports seasonal allergies. Denies any medical or surgical history. Soc Hx: Full time student at
high school and lives at home with parents and two younger siblings. During the week, plays football for
high school. He works part time on the weekends at McDonald’s. Has his license. He is not sexually
active. Denies any smoking or any forms of tobacco products. Denies any illicit drug or alcohol use.
Sleeps 6-8 hours most nights and exercises five days a week which includes cardio. Fam Hx: Mother
(living) is 49 with hypertension and dyslipidemia, no history of cancer. Father died of a car accident at 39
years old, he had a history of non-insulin dependent diabetes.
ALLERGIES: No history of hives, eczema or rhinitis. Reports seasonal allergies
Medications: None
ROS:
GENERAL: Positive for fatigue starting 3 days ago. Denies weight loss, reports fever and denies chills.
Reports recent decreased appetite.
HEENT: Denies hearing loss, sneezing, congestion. Positive for runny nose and sore throat. Positive for
voice hoarseness.
SKIN: No rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies nausea, vomiting or diarrhea. Denies abdominal pain or bloody stools. No
heartburn or indigestion. Reports formed, regular bowel movements.
NEUROLOGICAL: Denies dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities.
Positive for headaches without aura.
MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain or stiffness.
LYMPHATICS: Reports pain or swelling of lymph nodes behind her ears. Denies history of splenectomy.
Denies history of appendectomy or tonsillectomy. ENDOCRINOLOGIC: Denies of sweating, cold or heat
intolerance. Denies polyuria or polydipsia.
Objective:
VS: BP 118/62; P 84; R 15; T 97.8; 02 99% on room air, WT: 135lbs; HT: 5 foot 10 inches
General: Patient appears fatigued and well groomed. Color consistent with ethnicity.
Skin: Warm and dry. No bruises. Intact without rashes or lesions, no urticaria.
HEENT: Head atraumatic, midline, no tics or tremors noted. No facial swelling or tenderness. Pupils
equal, round, and reactive to light. No glasses or contacts. Smell intact, nose symmetrical. Pale, boggy
turbinate noted. Scant, clear discharge noted to bilateral nares. No polyps. Bilateral auricles symmetric.
Bilateral tympanic membranes pearly grey with light inspection. No pain or discharge from ear canals.
Oropharynx with mild erythema and no discharge. No swelling of the tongue, white patches on the oral
mucosa with slight edema of the uvula. Enlarged tonsils +3. Neck: Bilateral symmetry of the
sternocleidomastoid and trapezius muscles. Trachea midline. No JVD. No thyromegaly. Supple, no
masses or tenderness to palpation. Bilateral nontender 0.5cm anterior and posterior lymph nodes
palpable.
Cardiovascular: No murmur or gallops, S1 and S2. No edema noted.
Gastrointestinal: Abdomen is symmetrical, round, flat. Active bowel sounds in all quadrants. Soft,
nontender on palpation. No masses on palpation. Mild enlargement of spleen. No hepatomegaly.
Pulmonary: Lungs are clear to auscultation. No wheezing, cough, or congestion. No SOB or dyspnea. No
stridor.
Musculoskeletal: Full range of motion to all extremities. No pain, redness, or stiffness in all joints.
Neurological: Cranial nerves II to XII intact. Sensory intact. Motor is 5/5. No ataxia. Gait steady. Balance
intact. No weakness. No dizziness or loss of motor function.
The first part of the discussion board is to identify all pertinent positive and negative information.
Then make a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.
Second part is to make a plan utilizing clinical practice guidelines for the priority diagnosis.
