SUBJECTIVE: HPI-ROS: The patient states that she has been experiencing a sore throat for the past 5 days which keeps getting worse. She mentioned her family and friends, whom she'd been with at a birthday party a couple of days ago were sick. She also shared the same drink with her friend. She affirms having a fever, experiencing having a hard time swallowing, a swollen neck, and light-headedness. She already consulted a doctor who thought it was strep and was prescribed Amoxicillin but it doesn't relieve her sore throat. She noticed some rash in her abdomen but doesn't itch. She mentions there's a pain on the left side of her stomach. She denies cough, shortness of breath, chest pain, vomiting, nausea, change in bowels, urinary symptoms like burning, frequency & urgency, weak pain, and swelling. She also denies major illnesses and surgeries in the past. REVIEW OF SYSTEMS: General: Positive for fever, no change in strength or exercise tolerance. Head: Notable for light-headedness. Mouth: Positive for sore throat, no dental difficulties, no gingival bleeding, no use of dentures. Neck: Positive for swelling, no stiffness, no pain, no tenderness, no noted masses. Abdomen: Positive for left abdominal pain and abdominal rashes, no change in appetite, no dysphagia, no bowel habit changes, no emesis, no melena. OBJECTIVE: General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect. Eyes: Notable for blurry vision, no diplopia, no tearing, no scotomata, no pain. Nose: She has a dry mucous membrane, no epistaxis, no coryza, no obstruction, no discharge. Throat: She has pharyngeal erythema with exudates, hypertrophic tonsils, and moderate dysphonia with biochismism. Neck: She has anterior submandibular adenopathy and posterior cervical adenopathy. Heart: She has tachycardia with S4 gallop, 1 over 6 systolic ejection murmur. Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use of accessory muscles of respiration. Abdomen: She has a sore in the spleen edge one-finger breath below the left costal margin, Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.
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SUBJECTIVE:
HPI-ROS:
The patient states that she has been experiencing a sore throat for the past 5 days which keeps getting worse. She mentioned her family and friends, whom she'd been with at a birthday party a couple of days ago were sick. She also shared the same drink with her friend. She affirms having a fever, experiencing having a hard time swallowing, a swollen neck, and light-headedness. She already consulted a doctor who thought it was strep and was prescribed Amoxicillin but it doesn't relieve her sore throat. She noticed some rash in her abdomen but doesn't itch. She mentions there's a pain on the left side of her stomach. She denies cough, shortness of breath, chest pain, vomiting, nausea, change in bowels, urinary symptoms like burning, frequency & urgency, weak pain, and swelling. She also denies major illnesses and surgeries in the past.
REVIEW OF SYSTEMS:
General: Positive for fever, no change in strength or exercise tolerance.
Head: Notable for light-headedness.
Mouth: Positive for sore throat, no dental difficulties, no gingival bleeding, no use of dentures.
Neck: Positive for swelling, no stiffness, no pain, no tenderness, no noted masses.
Abdomen: Positive for left abdominal pain and abdominal rashes, no change in appetite, no dysphagia, no bowel habit changes, no emesis, no melena.
OBJECTIVE:
General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect.
Eyes: Notable for blurry vision, no diplopia, no tearing, no scotomata, no pain.
Nose: She has a dry mucous membrane, no epistaxis, no coryza, no obstruction, no discharge.
Throat: She has pharyngeal erythema with exudates, hypertrophic tonsils, and moderate dysphonia with biochismism.
Neck: She has anterior submandibular adenopathy and posterior cervical adenopathy.
Heart: She has tachycardia with S4 gallop, 1 over 6 systolic ejection murmur.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no
use of accessory muscles of respiration.
Abdomen: She has a sore in the spleen edge one-finger breath below the left costal margin,
Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.