CHIEF COMPLAINT:
Sore throat.
HISTORY OF PRESENT ILLNESS:
The patient is a (XX)-year-old female, who states that four days ago, she developed right ear pain. The following day, she developed left ear pain, sore throat, fever, and chills. She saw a doctor and was told her temperature was 38 degrees centigrade. The patient was given some naproxen and loratadine for her symptoms. She feels somewhat better. She still has the sore throat and ear pain, but it is less. She is able to swallow. She has not had a fever for two days. She denies head congestion, headache, chest pain, shortness of breath or cough. She is not aware of ill contacts. She was taking and continues to take malaria prophylaxis.
PAST MEDICAL HISTORY:
Negative.
MEDICATIONS:
Malarone.
ALLERGIES:
No known drug allergies.
SOCIAL HISTORY:
The patient is divorced and lives alone. She does not smoke cigarettes. She occasionally drinks alcoholic beverages.
REVIEW OF SYSTEMS:
The patient denies visual complaints, abdominal pain, nausea or vomiting, urinary or bowel symptoms, leg pain or swelling, joint pains, skin rash or other acute concerns.
PHYSICAL EXAMINATION:
The patient is awake, alert, and appears generally well. The patient is in no distress. Vital signs revealed a pulse of 96, respirations of 16, temperature of 99.6 and O2 saturation on room air of 100%. HEENT: Pupils are equal, round and reactive to light. There is no sinus tenderness. Ears are clear. Throat is slightly red without significant swelling or exudate. Neck is supple without adenopathy. Lungs are clear. Heart has regular rate and rhythm without murmur or gallop. Back showed no CVA tenderness. Abdomen is soft and nontender. No organomegaly. Extremities: No edema or tenderness. Skin: Normal color and turgor without rash.
A throat swab was obtained and sent to the lab for rapid strep testing and followup throat culture.
ASSESSMENT AND PLAN:
Pharyngitis. The patient was advised that we will contact her and treat her if either of her strep tests were positive. Otherwise, the patient will get extra rest, drink plenty of fluids, take some Advil or Tylenol for discomfort, and gargle with some warm salt water. If not significantly improved in a few days or if worse, the patient will contact her primary physician’s office.
