Daniel DeMarco Focused H&P#8 Ambulatory Care

Chief Complaint: Sore throat x 2d

 

History of Present Illness:

JH is a 22yo Female presenting to office with complaint of sore throat x 2d. States she has been having constant pain, “like knives in my throat,” since returning from a trip to Nashville, Tennessee. Admits bilateral ear pain. Denies fever, chills, nausea, vomiting, diarrhea. Tolerating PO fluids and regular diet. Patient admits intercourse with new sexual partner while on trip. She is unsure if he has a history of STDs. Denies vaginal discharge. Will have testing performed with GYN.

 

Allergies: NKDA

Medications: Lo Loestrin Fe 1mg-10mcg 1 tablet PO qd

PMH: Denies

PSH: Cholecystectomy 2014

Social History: Admits social EtOH use. Denies tobacco use, marijuana use, other illicit drug use.

Sexual History: Identifies as female. Has multiple male partners. No history of STDs. Uses protection during vaginal intercourse but not oral intercourse

Family History: Father, alive, DM2; Mother, alive, HTN

 

Review of Systems:

General: Denies fever, chills, anorexia, weight loss, weight gain

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays 

HEENT: Admits sore throat, ear pain. Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain, runny nose, congestion

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain, palpitations, history of murmur, fainting, or dizziness with activity 

Respiratory: Denies wheezing, shortness of breath, cough

GI: Denies nausea, vomiting (bloody/bilious), diarrhea, constipation, hematemesis, hematochezia, or melena

GU: Denies dysuria, frequency, urgency, hematuria

Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities

MS: Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Denies rashes, bruising, petechiae

Psychiatric: Denies HI/SI, feelings of helplessness, hopelessness

 

Physical Exam:

Vital Signs:

BP: 110/78

Pulse: 92bpm

RR: 16 breaths/min

Temp: 37.0C

SpO2: 98%RA

Ht: 64.0 inches

Wt: 65kg

 

General Survey: Alert, NAD. Appears stated age.

Skin: No petechiae, masses, lesions. No jaundice, cyanosis, mottling. No rashes.

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

Head: NC/AT. Non-tender to palpation throughout. Frontal and maxillary sinuses nontender to palpation and percussion.

Eyes: PERRLA. EOM intact and nonpainful. Red reflex present bilaterally. No crusting on lashes. No discharge.

Ears: External ear with no masses, lesions. Nontender to palpation. Auditory canal with no injection. B/L TMs pearly gray with cone of light in appropriate position.

Nose: Nares patent. Mucosa pink. Septum midline. Turbinates non-boggy, non-hyperemic.

Throat: Moderate pharyngeal erythema. Good dentition. Gingiva without lesions, masses. Uvula midline. No tonsillar swelling. 

Neck: Supple. No thyromegaly. No lymphadenopathy.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

 

Assessment/Plan:

JH is a 22yo Female with 2d complaint of sore throat that is worsening concerning for Strep pharyngitis versus Gonococcal pharyngitis.

 

#Streptococcal Pharyngitis

– Rapid Strep Positive

– Throat culture sent to r/o: Gonococcal infection

– Start Amoxicillin Tablet 875mg 1 tablet PO q12h x 10d

– Continue PO fluid intake, diet as tolerated

– OTC IBU/APAP prn for pain/fever

– If worsening/persistent symptoms return to clinic

– If respiratory distress go straight to ER

 

Follow-Up: prn

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student