PATIENT INFORMATION: S.J. is a 17-year old, Male, Caucasian.
CHIEF COMPLAINT: Sore throat for 2 days
HISTORY OF PRESENT ILLNESS:
Patient is a 17-year old male, brought in by mother for sore throat. Symptoms started 2 days ago with increasing severity. Patient describes pain as 9/10 on pain scale, associated with difficulty swallowing, hoarseness accompanied with headache, some body weakness and a fever with maximum reading of 101.9 degrees Fahrenheit. It is made worse with eating and trying to swallow food. He has tried drinking warm lemon juice affording some throat relief. He has also been taking Tylenol affording resolution of the fever.
Patient reported he was exposed to his classmate with similar symptoms 1 day before the appearance of his symptoms.
ALLERGIES: No known drug and food allergies.
PAST MEDICAL HISTORY: Patient denied any previous hospitalization.
SURGICAL HISTORY: Patient denies any previous surgery.
FAMILY HISTORY: Family history is non-contributory.
SOCIAL HISTORY: S.J. is a high school student, denies use of alcohol drinks, tobacco or illicit drug use.
Sexual History: Sexually active; in a monogamous relationship.
ROS: Significant for HEENT: (+) headache, no vertigo, dizziness or lightheadedness, no blurring of vision, no double vision, no tearing, (+) sore throat, dysphagia, hoarseness, no ringing in the ears, (+) ear pain bilaterally, worst with swallowing, no neck pain.
PE findings: Significant for throat findings i.e., pharyngeal walls pink, (3+) size tonsils, cherry red, and swollen with yellowish exudate. Additionally, patient has enlarged cervical lymph nodes bilaterally.
Other ROS and PE findings are unremarkable.
