Sore Throat

HISTORY:

Sore throat for ‍ ‍hoursdays

Severity: ‍mildmoderatesevere, ‍012345678910 / 10

Radiation: ‍none

Treatments tried: ‍none, ‍effectiveineffective

Contact with strep throat: ‍yesno

‍pain with swallowing

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍runny nose, ‍clearcolored

‍nasal congestion

‍difficulty breathing

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍rash

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍earache

‍swollen lymph nodes

‍voice changes

‍redness in throat

‍white patches/pus on tonsils

‍swelling in throat

‍drooling

‍muffled voice

‍inability to open mouth fully



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Skin: ‍no rash



ASSESSMENT:

‍Pharyngitis ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Rapid strep test

- Throat swab

- Chlamydia and gonorrhea throat swab

- Blood work: ‍CBC, ‍monospot test, ‍LFTs, ‍CRP, ‍ß-hCG

- ‍Analgesics

- ‍Antibiotics

- ‍Dexamethasone

- Tantum lozenges

- Salt water gargles 4 times daily

- Rest and hydration

- Limit contact with others

- Follow-up in ‍ ‍daysweeks

- Return if does not improve after 72 hrs or before if worsens

- Referral to ENT specialist if symptoms persist