CC (Chief Complaint): Cough And Sore Urc

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CC (Chief Complaint): “Cough and sore throat X 3 days”.
PHI: Mr. M. B is a 38 year old black male who presents in the clinic with c/o cough and sore throat over the last 3 days. The patient reported productive cough with greenish sputum. Patient also reported nasal stuffiness, post nasal drip, and itchiness in ears, eyes, and nose. The onset of CC started 3 days ago. M.B. Described sore throat as a dull aching pain, constant 10/10 which is aggravated by coughing and swallowing. Patient took over the counter medications (OTC) Motrin and a cough syrup w/o relief. The patient denies having this illness before. The patient’s sleep pattern is disrupted by this chief complaint. Patient c/o fever, chills, malaise, and decrease appetite.
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• Encouraged patient to bring BMI to < 25.0
• Monitor blood pressure weekly and record readings and bring to the next follow visit appointment in 3 weeks.
Evidence-Based Rationale:
One of the most common causes of bacterial pharyngitis or tonsillitis is group A streptococci (GAS). This infection is most prevalent in the winter time. It is estimated that 15% to 25% of pharyngitis cases in children are caused by GAS. GAS is transmitted by direct contact with respiratory secretions or large droplets, and the incubation period is between 2 and 5 days. The patient usually presents complaining of sudden onset of sore throat, painful swallowing, fever, chills, headache, nausea, vomiting, and cough (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2013).
Patients with acute GAS pharyngitis should be treated with an appropriate antibiotic at an appropriate dose for a duration likely to eradicate the organism from the pharynx (usually 10 days). Based on their narrow spectrum of activity, infrequency of adverse reactions, and modest cost, penicillin or amoxicillin is the recommended drug of choice for those non-allergic to these agents (AHRQ,

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