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Case Study: Sore throat Patient Information: L.A., 25 year-old, male, college student

Chief Complaint: Sore throat History of Present Illness Onset: 7 days ago however, since yesterday, he has noticed that his eyes and skin have turned a yellow color. Location: throat associated with swollen and tender neck glands. (is the symptom located in a particular place? if no particular location, you can put “generalized”) Duration: 7 days ago, he developed fever which was low (99 F) to moderate grade (101.1 F). This was associated with swollen and tender neck glands. (how long has the condition lasted? recent or chronic?constant or intermittent? same as past problem and what has been done at that time? is it getting better, same or worse?) Characteristics/Course: He has sore throat but denies having cough, associated with swollen and tender neck glands. Denies abdominal pain but feels as if his upper abdomen has become swollen and he has lost his appetite. Aggravating/Associated Factors: Unknown Relieving Factors: Unknown Treatment: He denies taking any medications. Allergy: Unknown Past Medical History: Patient denied any history of jaundice, hepatitis, blood transfusion, body piercing, tattoos or eating shellfish. Surgical History: Patient denied previous surgery. No known drug allergies. Family History: Family history is non-contributory. Social History: Patient is a collage student who denied use of tobacco, alcoholic drinks or illicit drug.

Review of Systems: Constitutional: Patient is well-developed, in no acute distress. He appears concerned and anxious. Skin – no rashes, no itching, no hair changes or hair loss, no nail changes. HEENT – PERRLA, EOMI, (+) icteric sclerae, (+) pink conjunctivae, T-P erythematous with exudates, no vertigo, no lightheadedness; no blurring of vision, no double vision no tearing; (+) sore throat; no ear discharge, no ringing in the ears, no ear pain, (+)swollen and tender neck glands Cardiovascular – no chest pain, no palpitation Respiratory – no difficulty breathing, no cough Gastrointestinal – (+) loss of appetite, no nausea, no vomiting, no changes in bowel habits Genitourinary – no changes in urination, no pain in urination, Neurologic – no difficulties with speech, memory and motor coordination; no numbness or tingling sensation Musculoskeletal – (+) muscle aches, no pain or tenderness of the joints, no muscular weakness or cramps. Hematologic: No anemia, bleeding or bruising. Lymphatics: (+) enlarged nodes. Psychiatric: appears concerned and anxious no change in orientation Endocrine: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. Allergies: no seasonal allergies

 

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