Patient pains or coughs Gastrointestinal: has she noticed any

Patient
Name: Lily          
       Age: 20 years                    
Gender: Female

SUBJECTIVE
DATA:

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Chief
Complaint (CC): sore throat 

History
of Present Illness (HPI): Lily is a 20
years old female student at the local community college who presents with a three
day history of sore throat.

Appropriate
history to take: does she have any pain or difficulty
swallowing, any change on her voice, does she have nausea, diarrhea or
constipation, does she have any headaches or changes in vision, does she have
any difficulty in breathing, does she have any pain or discomfort in the ears,
does she feel easily fatigued, has she shared utensils or been very close to
anyone with symptoms like hers in the recent past

Current Medications: what medications is she currently on if any

Food
and Drug Allergies: has she ever had an
allergic reaction to any foods, drugs or materials and which ones were they if
any.

Past
Medical History (PMH): has she
ever had any surgery for any reason, any history of blood transfusion or
admission into a hospital for any illness.

Sexual
and Reproductive History: Is she in any
relationship and sexually active, does she have any children, does her partner
also have similar symptoms, does she have a history of a sexually transmitted
infection

Family and Social
History: Does she smoke
cigarettes, drink alcohol or use any other kinds of recreational drugs, does
she have any siblings and what is their health status, are her parent alive and
in good health. Is she aware of any chronic diseases such as diabetes, asthma,
hypertension within her immediate family members?

 Review
of Systems:

Cardiovascular System: does she
have any palpitations, chest pain, leg swellings or easy fatigability

Respiratory System:  does she have any pleuritic chest pains or
coughs

Gastrointestinal:  has she
noticed any change in her bowel habits?

Genitourinary: does she
have any abnormal discharges, pain with micturition or burning sensations?

Neurological:  has she
experienced any convulsions, changes in vision or headaches?

OBJECTIVE

Appropriate
physical examination

General exam:  check for
general appearance; nutritional status, her gait and demeanor, edema,
lymphadenopathy and jaundice.

Check vital signs including blood pressure,
temperature, respiratory rate and pulse rate are all within normal range.

ENT examination:

Observation:  has a runny nose, slight hoarseness of voice
but does not sound congested. Check for presence of inflamed tonsils or
pharynx, check the oral mucosa for ulcerations and thrush, and check the level
of dental and oral health and for any signs of alteration on the skin of the
neck.

Palpation:
of the neck for lymphadenopathy, changes in skin consistency and temperature.

Other physical Exam: Examination of the ear

ASSESSMENT

Differential diagnoses: 

Pharyngitis:
inflammation of the pharynx caused commonly by viruses including
influenza and herpes and common symptoms are sore throat, dysphagia and
sometimes otalgia (Bisno, Gerber, Gwaltney Jr, Kaplan, & Schwartz ,2002).

Tonsillitis:
the tonsils in the mouth can get inflamed due to infection with viruses and
bacteria and these can present with sore throat, fever and difficulty or pain
in swallowing (Bisno et al. 2002).

Infectious
mononucleosis: is an infection commonly caused by the Epstein-Barr
Virus. Other causes include Cytomegalovirus and herpes. It presents with
flu-like symptoms and is highly contagious especially among adolescents and in
people in close contact e.g during kissing (Macsween & Johannessen, 2014).

Infectious
Esophagitis: irritation of the esophagus caused by infections including
fungi, bacteria and viruses and presenting with dysphagia and sometimes upper
chest pains.

 PLAN

Diagnostic tests:

Throat Swabs for
Microscopy, culture and sensitivity. If the symptoms are due to infections, the
offending pathogens are likely to be visualized in a throat swab specimen and
identified for proper treatment (Johansson
& Månsson, 2003).

Rapid Antigen Testing:
this can be used to identify viral antigens especially for influenza A and
B viruses that are usually implicated in flu.

Anti-Streptolysin O Titers
(ASOT) test: The commonest cause of sore throat is streptococcus pyogenes
and they secrete anti-streptolysin O enzyme against the host cells. Determining
the levels (titers) of this enzyme enable diagnosis of acute infection by these
organisms (Johansson & Månsson, 2003).

Monospot Test: In
response to infection by the Epstein – Barr virus, the immune system secretes
heterophile antibodies that are detected by this test to rule out or rule in
Infectious mononucleosis (Macsween
& Johannessen, 2014).

Esophageal Endoscopy: involves passing a thin scope through the
mouth to visualize the esophagus and look for any signs of pathology (Guilford, 1990).