CC: “I have a sore throat and raspy voice for the last 2 days”
HPI: M.N. is 45-year-old women with a PMH of anxiety and HTN who presents to the office complaining of a sore throat and raspy voice for the last two days. The pain is located both sides of her throat with radiating up to her head causing a headache, 4/10 x 1 day. She describes the pain as sharp, 5/10, and worst when swallowing. She took two 200mg Advil and lozenge with no relief. She admits to having some chills and feeling “feverish” but she did not take her temperature. Denies, rhinorrhea, cough, hoarseness, difficulty breathing, and headache.
PMH:
Anxiety: (diagnosed at age 24, take Seroquel and Xanax PRN)
HTN: (Diagnosed at age 43, controlled with amlodipine 5mg)
Surgery: Hysterectomy at age 40
Last Hospitalizations: OMC during hysterectomy x 3 days
Health immunizations: Up to date with COVID and flu vaccines, up to date on childhood vaccines
Medications:
-Seroquel 25mg QD
-Alprazolam 0.25mg Q8 hours PRN
-Amlodipine 5mg PO QD
Allergies:
-Denies latex, drug, environmental, pet, and food allergies
Family History:
-Father (Deceased age 78) MI, HTN, CHF
-Mother (Alive, age 88) DM, HTN, CHF, Dementia
-Brother (Alive, age 50) CAD, HTN, HLD
Social History:
Occupation: RN at RWJ
Education: Bachelor’s degree in nursing
Living situation: Lives with her husband and 2 kids at home. Feel safe at home. no pets at home.
Diet: Reports healthy, balanced diet. Breakfast: bagel, toast, or eggs. Lunch: salad or sandwich. Dinner: chicken, steak with vegetables. Reports drinking 6-7 glasses of water per day. Admits to drinking 1 cup of coffee per day. Denies recent changes to diet or hydration.
Substance/tobacco abuse: Denies tobacco and illicit drug use. Drinks 1 glass of wine with dinner 4-5 times a week.
Physical activity: Does not exercise
Sleep: Denies any sleeping disturbances. Sleeps 8-9 hours per night.
ROS
General: Denies weight change, recent illness, nights sweats, insomnia, weakness, fatigue.
HEENT: See HPI. Denies head trauma, lesions, vision problems/the use of corrective lenses, tearing, blurriness, auditory changes, ear pressure/pain, tinnitus, vertigo, epistaxis, rhinitis.
Respiratory: Denies shortness of breath, cough, wheezing, dyspnea, respiratory infections.
Cardiovascular: Denies chest pain, chest tightness, palpitations, tachycardia, heart murmurs, edema.
OBJECTIVE
Vitals: • Temp: 99°F • BP: 134/88• HR: 68 BPM • RR: 18 BPM• O2 Sat: 98% on room air•
Physical Exam
General: M.N. is alert and oriented, seated upright on the examination table, and does not appear to be in any acute distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
HEENT: Head normocephalic and atraumatic. Facial features symmetric. No visible abnormal findings noted in the right or left fundus. Disc margins sharp bilaterally. Auditory canals appear pink, TM is intact and pearly gray, and no discharge present bilaterally. Nasal mucosa inflamed with expected patency. No nasal discharge, polyps, foreign bodies, lesions, deviated/perforated septum visible. Oral mucosa is moist and pink. Tongue pink and moist. Posterior oropharynx erythema and pharyngeal swelling noted. Tonsillar swelling 2+ with no exudates. No anterior cervical adenopathy noted.
Respiratory: Chest is symmetric bilaterally with no lesions or deformities. Chest rise is symmetrical with respirations. Lungs are clear with auscultation in all lung fields with no cough, wheezing, crackles, rhonchi, or rales.
Cardiovascular: Heart rate is regular, S1 and S2 present with no murmurs, gallops, rubs. PMI present at the midclavicular line and 5th intercoastal space. No bruit in the bilateral carotids on auscultation. Carotid arteries +2 with no thrill on palpation.
Labs/other tests
–Rapid COVID test done in office: Negative
-Rapid strep test done in office: Negative
-Influenza A/B: Negative
-No labs reviewed with this visit
Assessment:
-Viral Pharyngitis: M.N. presents with sore throat, headache, and hoarseness. She did not have any fevers, exudates, or adenopathy. Strep in the office is negative.
-Anxiety: controlled, follows with psychiatrist, on Seroquel and Alprazolam PRN
-HTN: Controlled on amlodipine 5mg QD
Plan:
Viral Pharyngitis (J02.9)
-Throat Lozenges, ice chips, hard candies
-warm saltwater gargles 4-5 times a day
-Tylenol 500mg q4-6 hours if needed for fevers, monitor for fevers
-educate on drinking plenty of fluids, plenty of rest
-humidifier to moisturize the room
-No referral or further testing needed at this time
-Call office if symptoms worsen or do not improve in 5-7 days
HTN (I10.0)
-Continue amlodipine 5mg BID
-Monitor BP at home during acute illness
-Continue with outpatient cardiology follow-ups
Anxiety (F41.1)
-Continue Xanax PRN
-Continue Seroquel
-continue with outpatient psychiatry follow-up
Differential diagnosis:
-Mononucleosis
-Tonsilitis
-Postnasal drip secondary to allergies
