24 year old male presents to the clinic with complaints of a worsening sore throat that began two days ago. He rates hispain as a 5/10 and describes it as scratchy and achy. He reports subjective feve r last night. He had chills but did not takehis temperature. No recent URI or present symptoms suc...
Northern Kentucky University MSN 610: Diagnostic Reasoning and Advanced Physical Assessment Comprehensive History & Physical Exam DEMOGRAPHICS Providers Name: _____Patient’s Initials: (Data Source ) CR Date of Exam: 07/17/202 3 Patient’s DOB/AGE: 04/02/1997 (24) Chief Complaint: “Sore throat that began a couple of days ago” Gender/Sexual Orientation : Male/Straight History of Present Illness: 24 year old male presents to the clinic with complaints of a worsening sore throat that began two days ago. He rates his pain as a 5/10 and describes it as scratchy and achy. He reports subjective fever last night. He had chills but did not take his temperature. No recent URI or present symptoms such as runny nose, cough or shortness of breath. Reports that he tried taking ibuprofen for the pain with little relief. He does feel that drinking cold ice water helps soothe his throat. Swallowing makes the pain worse and it is also worse in the morning time per the patient. Patient denies nausea, vomiting or diarrhea. Denies rash. Denies being around any sick contacts. No one in his family or circle of friends smokes. Denies history of sinus infections or strep throat. PMH: generally healthy. Mild asthma that he manages with an inhaler as needed. Denies ever using tobacco, alcohol or recreational drugs. Past Medical History: Active Problems : Asthma Resolved Problems: Pneumonia; Bronchitis; torn left meniscus, concussion Previous Hospital izations: Denies history of hospitalization Surgical History: s/p left meniscus repair s/p wisdom teeth removal Allergies: NKDA; cats and dogs Current Medications : Albuterol Inhaler 90 mcg 2 puffs every 4-6 hours as needed for shortness of breath or wheezing. Ibuprofen 200mg 2 tablets every 4 hours as needed for pain, headache and fever. Social History : Living Arrangements: This patient lives in Brighton, IL with his wife of two years. They have no children. Occupat ion: He has his Associate Degree in applied science and works as a lead technician at World Wide Technology in Wood River, IL. Environmental Safety: Pt reports adherence with safety protocols at his workplace and denies exposure to harmful chemicals. Smoking: Denies tobacco use. Alcohol: Denies alcohol use. Drugs: Denies illicit drug use. Diet: Regular Activity Level/Hobbies: Pt reports having an active lifestyle. He is on his feet a lot for work and enjoys coaching football in his spare time. Reproductive & Sexual History: Denies any STI history. Other Non-Prescribed Drugs: Pt denies use of vitamins, supplements or other over-the-counter medications. Family History: Relationship Living or Deceased Age Illnesses Mother Living 51 Hypothyroidism Father Living 51 Healthy Maternal Grandmother Living 75 Hypertension Maternal Grandfather Deceased (58) Myocardial Infarction (cause of death); Hypertension Paternal Grandmother Living 76 Breast Cancer Paternal Grandfather Living 79 Coronary Artery Disease; Hypertension Preventative Health/ Anticipatory Guidance: (Age Appropriate) 1. Safety Issues: Potential risk for injury at the workplace: Recommended that patient adhere to the protocols that are in place and wear steel toe shoes. Reinforced seatbelt safety education and the importance of not texting and driving 2. Screenings: Encouraged routine dental/vision checkups 3. Immunizations: Patient reports that he received all of his childhood vaccinations. Recommended that he receive the annual flu vaccine; COVID vaccine Review of Systems: General: Pt appears to be a healthy, well-nourished 24 year-old male. Pt denies any recent weight gain/loss, appetite changes, problems sleeping or weakness. Pt reports subjective signs of a fever. Skin, Hair, Nails: No color changes, rashes, sores, pain, pruritis, hemorrhages, hair loss/pattern or changes in nails. HEENT: Pt denies headache, migraine, vision changes, cataracts, diplopia, otalgia, otorrhea, hearing changes, rhinorrhea, epistaxis, sinus drainage, dental pain/missing teeth jaw pain or clicking. Pt reports having a sore throat that began two
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