IHUMAN CASE STUDY
(NEW)- AMANDA
WHEATON - 23YRS OLD
FEMALE CC: SORE THROAT
COMPLETE 2023
iHuman Case Study (NEW)- Amanda Wheaton - 23yrs
... [Show More] Old Female CC: Sore throat
HPI: A.W. is a generally healthy 23 YO female who presents with chief complaint of sore throat
and associated headache, fever, and swollen neck glands for 2 days. States she is taking Tylenol
for fever andeating ice cream to alleviate sore throat. The pain in the throat is 11/10 and "feels
like an ice pic". Statesshe is also not trying to talk as much due to pain.
PMH: infectious mononucleosis at age 15, up to date on immunizations, has not gotten flu shot
this year
Current Medications: OTC Acetaminophen, OCP -Drospirenone/Ethinyl Estradiol
Allergies: No known drug allergies
Preventive Health: birth control pills, condoms
Family
Hx: mother - hypertension
Social Hx: Denies smoking, socially drinks 2-3 drinks a week with fellow law school students,
sexuallyactive with one male partner, lives with one roommate who had a sore throat earlier this
week
Focused ROS:
Constitutional- fever, chills. Denies weakness, fatigue.
Neuro - Headache. Denies numbness, tingling, lightheadedness, neck stiffness.
HEENT - Sore throat, hoarseness. Denies eye redness, eye discharge, earache, oral ulcers,
congestion,rhinorrhea.
Respiratory - Denies cough, difficulty
breathing.Cardiac - Denies chest pain.
GI - Denies appetite change, food intolerance.
Focused PE findings:
General - temp 101.5 F, BP 124/80 right arm, HR 96, RR 16, O2 98% RA, alert and oriented x4,
ageappropriate, mild distress, non-toxic appearing.
Skin - warm to touch. No diaphoresis, rashes noted.
Head/neck - Normocephalic, full ROM of neck, no tenderness to posterior neck, tenderness to
bilateralanterior neck, bilateral anterior cervical lymphadenopathy with mobile rubbery
lymphnodes about 1.5cm in size.
EENT - Eyes- PERRLA. No erythema, drainage, swelling noted. Ears - No tenderness to
palpation, drainage, erythema or bulging to TM noted. Nose - No erythema, drainage, or
tenderness to palpation noted. Throat - Posterior pharyngeal erythema. No ulcers. Normal
dentition and gums. Tonsils are mildto moderately enlarged with prominent exudates bilaterally.
Swallowing normal with thyroid moving normally.
Respiratory - clear to all lung fields.
Diagnostic tests -
Influenza PCR (nasal swab)- negative
Rapid strep antigen detection test (RST/RADT)- negative
throat culture - growth of gram positive cocci in clusters and pairs with complete hemolysis
Medications -
Penicillin V 250mg PO every 6 hours for 10 days ; antibiotic
Acetaminophen 650mg PO every 8 hours for 10 days ; antipyretic and analgesic
(Mustafa & Ghaffari, 2020).
Suggested consults/referrals - No consults or referrals at this time. If symptoms of the tonsils
worsen,referral to an ENT specialist may be needed.
Client education -
Wash your hands often.
Do not drink from the same glass, eat from the same plate, or share utensils with anyone.
Stay home from school and separate yourself from your partner and roommate until you no
longer havea fever and have taken antibiotics for at least 12 hours. This will help keep others
from getting sick.
Please take full course of antibiotics even though you are starting to feel bett [Show Less]