Patient Name Sally Kleinfelder___ Physician Dr. Michael Green

Date: Monday, April, 5.

cc: " fever and sore throat" Temp.= 104^oF, BP= 122/75, AR= 70, RR= 18

S/

• Pt. complains of very sore throat that has lasted about 4 days.
• Notes fever of 102-104^oF started at about the same time as the sore throat.
• Pt. also mentions joint aches and pains
• Fever goes down with Tylenol and helps the sore throat a little.
• Mother is worried she may have strept. throat
• Needs excuse for school.

O/

• General: Pt. appears tired and pale. Noted pain when the patient attempts to swallow.
• HEENT:
• Ears- TM's appear clear, good cone of light, no retraction or injection.
• Nose- slightly swollen mucosa
• Throat- very erythematous oral pharyngeal region, pus noted on tonsils, tonsils present.
• Neck- supple, noted lymphadenopathy; very tender nodes. No thyromegaly.
• Lungs: clear to percussion and auscultation, no adventitious sounds noted.
• HRRR: good heart sounds, no murmurs, thrills, rubs or extra heart sounds.
• Skin: No rashes, pale, nail beds okay, minor acne on face.
• Streptococcal rapid antigen test: Swabbed pt. throat and tested for strept. antigen with rapid antigen test. Result: Negative.

A/

• Pharyngitis
• Probable viral sore throat
• consider; strept. throat, infectious mononucleosis

P/

• Treatment plan; Tylenol for fever and pain, salt water gargles to relieve throat pain, stay home from school and rest until fever goes down.
• Diagnostic evaluations; Strept. throat unlikely with neg. antigen test.
• Disposition; outpatient care; No antibiotics however if pt. doesn't get well in 3-5 days tell her to return. Issued excuse for pt. to miss school until well.