Are your immunizations up to date.

Reason for encounter: “i have a really bad sore throat”

HPI:

The patient is a 23-year-old female who presents to the clinic with a sore throat and a fever of

101.5 that began two days ago. She also complains of a headache that comes and goes as well as

swollen and tender b/l glands on her neck. She reported that her sore throat began suddenly two

days ago. She reports that he sore throat pain is constant but her headaches and fever comes and

goes. She describes her sore throat as an ice pick in her throat and rates her pain as an 11 on a

scale of 1-10. Tylenol appears to alleviate her sore throat, fever and headaches; ice cream appears

to alleviate her sore throat and swollen glands. The patient reports that she has not received her

influenza vaccine but is up to date on all other immunizations. She also states that she is in a

monogamous relationship where she occasionally performs and receives oral intercourse. The

patient reports that her roommate had a bad sore throat earlier in the week; however, she is

unaware of what her diagnosis was.

ROS:

General: denies weight loss, malaise, chills, or night sweats. Pt is currently febrile. Patient is a

good historian for her health hx

HEENT/ Neck :

head: occasional headaches; denies any head trauma

eyes: denies eye pain, redness, or discharge

ears: denies ear pain or discharge

Nose: denies nasal congestion

throat: sore throat that is an 11/10 severity with an ice pick characteristic. Pt c/o dysphagia

neck: swollen b/l glands

Cardiovascular: negative

Respiratory: denies cough or difficulty breathing

Gastrointestinal: negative

Genitourinary: negative

Musculoskeletal/ Osteopathic structural examination: negative

Neurologic : negative

Integumentary/ breast: negative

Psychiatric: negative

Endocrine:

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