Ms. Rebecca Fields, a 23-year-old Law student, comes to the clinic for evaluation of a sore throat which started about 2 days ago, suddenly along with fever. She states that her roommate had a bad cold sore a week ago. She states she has never experienced sore throat before. Currently, the pain is 10/10. She states a sore throat hurts when swallowing liquids and solids. Member states both sides of her neck is sore and tender. She states she has tried over the counter analgesics- Tylenol every 6 hours which helps to relieve the fever and ice cream seems to be soothing to her throat but doesn't completely relieve it completely.
She also complains of a mild headache, swollen glands, and hoarse voice. She denies any cough, nasal discharge, body …show more content…
Nails without clubbing or cyanosis. No rash, petechiae, moles, nevi or ecchymoses
HEENT/NECK
Head- Normocephalic, atraumatic, mild headache.
Eyes- Pupils equal round, reactive to light and accommodation; constricts from 5mm to 2mm. Disc margins sharp, fundi without hemorrhages or exudates.
Ear- Normal appearing external structures, no deformities, discharges or edema noted. clear tympanic membrane bilaterally. H test- negative for nystagmus
Nose- Normal nasal mucosa, no drainage, edema or polyps noted. No edema or tenderness over frontal and maxillary sinus.
Mouth- Tonsils are mild to moderately enlarged, posterior pharyngeal erythema, prominent exudate noted bilaterally, No oral ulcer or vesicles noted. Normal dentition, no odor or evidence of infection noted.
Neck-No visible scars, deformities or lesions noted. The trachea is midline and freely mobile. There is bilateral cervical lymphadenopathy, nodes are 1.5cm in size, rubbery and mobile, Thyroid moves with swallowing. The neck is supple with good range of motion. Normal JVD noted
Cardio
JVD normal; 6cm above the right atrium, carotid upstrokes brisk, without bruits.PMI is not palpable.Good S1, S2; no S3 or S4; no murmur, rubs or clicks noted.
She also complains of a mild headache, swollen glands, and hoarse voice. She denies any cough, nasal discharge, body …show more content…
Nails without clubbing or cyanosis. No rash, petechiae, moles, nevi or ecchymoses
HEENT/NECK
Head- Normocephalic, atraumatic, mild headache.
Eyes- Pupils equal round, reactive to light and accommodation; constricts from 5mm to 2mm. Disc margins sharp, fundi without hemorrhages or exudates.
Ear- Normal appearing external structures, no deformities, discharges or edema noted. clear tympanic membrane bilaterally. H test- negative for nystagmus
Nose- Normal nasal mucosa, no drainage, edema or polyps noted. No edema or tenderness over frontal and maxillary sinus.
Mouth- Tonsils are mild to moderately enlarged, posterior pharyngeal erythema, prominent exudate noted bilaterally, No oral ulcer or vesicles noted. Normal dentition, no odor or evidence of infection noted.
Neck-No visible scars, deformities or lesions noted. The trachea is midline and freely mobile. There is bilateral cervical lymphadenopathy, nodes are 1.5cm in size, rubbery and mobile, Thyroid moves with swallowing. The neck is supple with good range of motion. Normal JVD noted
Cardio
JVD normal; 6cm above the right atrium, carotid upstrokes brisk, without bruits.PMI is not palpable.Good S1, S2; no S3 or S4; no murmur, rubs or clicks noted.