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Monday, September 17, 2007

Pharyngitis Writeup for Nurse Practitioners

Patient Profile: J.W., 37 year old male, married, car salesman

Chief Complaint: “I’ve had a sore throat for a week and noticed white patches on my tonsils.”

History of Present Illness: Pt states “sore throat” started three days prior to office visit. Pt states that he has been “eating cough drops” to ease the pain. Upon noticing white patches, decided to come in for an assessment. Pt describes burning pain level 6/10 in the back of throat. Low grade temperature noted from previous evening.

Past Health History: Patient states chicken pox and roseola measles as a child with immunizations completed according to schedule. Past injuries include: “fractured” –femur at age of 12 and stitches to left hand at age 24. Past surgeries include: laparoscopic cholecystectomy (2000), and open appendectomy (2002).

Family History:
Paternal grandfather (72) deceased
HTN, DM (Type II) Maternal grandfather (77) alive
Paternal grandmother (69) alive
HTN, glaucoma, DM (Type II) Maternal grandmother (73) alive
Father (56) deceased HTN, Lung Cancer Mother (58) Healthy
Patient (37) HTN, DM (Type II)
Brother (42) HTN, DM (Type II)
Sister (34) Healthy

Current Health: No known allergies. Denies alcohol and drug use. Smokes cigars (one pack of 5 daily). Drinks two cups of coffee in the morning and drinks water rest of day. States gets moderate exercise by walking daily. States sleeps approximately 8 hours nightly. States HTN and Type II DM.
Medications: Lotensin 10mg daily, Glucotrol 10mg BID, Glucophage 500mg daily, HCTZ 25mg daily

Psychosocial History: States happily married with two children. Owns home and works full time. Considers self lower middle class. Adequate insurance reported. Graduated high school. Never went to college.

Review of Systems:
General condition: States no weakness, fatigue, chills, or weight loss. States low grade temp since last night.
Skin, hair, nails: No changes in color, texture, chronic marks, pruritis, odors, alopecia or rashes.
Head and Neck: No headache, syncope, vertigo, or stiffness reported. States difficulty swallowing secondary to sore throat.
Eyes: Reports 20/20 visual acuity. Date of last exam 10/20/05, no reported itching, discharge or pain.
Ears: No reported pain, tinnitus, discharge or use of hearing aids.
Nose, Mouth, Throat, Sinuses: No epistaxis, discharge, pressure or congestion reported. No hoarseness or oral lesions reported. States sore throat and “visible white patches”.
Dentition: Date of last exam 09/12/05. No cavities filled. No missing teeth or dentures reported.
Breasts: No masses, discharge or gynecomastia reported.
Respiratory: No reported cough, dyspnea, sneezing, pain on inspiration, or shortness of breath at rest or exertion.
Cardiovascular: No reported pain, palpitations, edema, cough Last B/P 137/71
GI: No reported pain, nausea, vomiting, constipation, diarrhea, or indigestion
GU: No dysuria, hematuria, frequency, or incontinence
Genito-Reproductive: No reported penile discharge, lesions, prostatic problems, impotence, states sexual relationship with wife satisfactory.
Musculoskeletal: No reported myalgia, stiffness, swelling or deformity.
Neurological: No reported seizures, tremors, memory disorders, paralysis, paresthesia, weakness, or dizziness.
Psychiatric: No reported depression, anxiety, or mood changes.
Endocrine: No reported goiter, heat/cold intolerance.
Hematopoietic: No reported bleeding, bruising, anemia, blood type A+.
Lymphatic: States swollen tonsils with white patches and pain.

DX: Tonsillitis, Pharyngitis

Medical Treatment: Usually some kind of penicillin. Amoxil 500 TID x 10 days etc.