Chief Complaint:
“My throat is so sore, it’s becoming hard to swallow. There are painful lumps on my neck, and I’ve been having fevers.”
History of present illness:
Miss J.K. is a 17 y.o. African American female who is being seen at an urgent care center by a family nurse practitioner after complaining of having a sore throat, fever, and swollen lymph nodes for three days. The sore throat has been increasing in severity since its onset. The patient is an athlete, and has been increasingly fatigued over the past couple of days as well.
Past Medical/Surgical History:
- Tonsillectomy, age 8
- Chronic sinusitis since age 12
Pertinent family history:
- Brother (age 20) experienced similar symptoms about a month prior to pt’s onset of symptoms
Pertinent social history:
- Runs track & field
- Has a boyfriend
- Lives with several other family members, including younger brothers and sisters, in a small apartment
- High school student
Allergies:
- Egg
- Sulfa antibiotics
- Seasonal
- Tree Nuts
Medications:
- Loratidine 10 mg PO Q24h
- Lo Loestrin Fe 10 mcg PO Q24h
Focused physical exam:
Skin
- Flushed, warm, and dry
- Swollen cervical lymph nodes, tender to palpation and mobile
- Swollen axillary lymph nodes, tender to palpation and mobile
Throat
- Mild swelling
- Red appearance
Miscellaneous:
- Oral temperature of 101.9 F