iHuman Case Study (NEW)- Amanda Wheaton - 23yrs Old Female CC: Sore throat
HPI: A.W. is a generally healthy 23 YO female who presents with chief
... [Show More] complaint of sore throat
and associated headache, fever, and swollen neck glands for 2 days. States she is taking Tylenol
for fever and eating ice cream to alleviate sore throat. The pain in the throat is 11/10 and "feels
like an ice pic". States she 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,
sexually active 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,
age appropriate, 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
bilateral anterior 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 mild to moderately enlarged with prominent exudates bilaterally.
Swallowing normal with thyroid moving normally. [Show Less]