DATE OF SERVICE: MM/DD/YYYY
REASON FOR VISIT: Pharyngitis.
SUBJECTIVE: The patient is a (XX)-year-old male with a past medical history of acute pharyngitis who presents with a 1-week history of feeling itchy throat and having chest congestion.
The symptoms are milder from yesterday; although, mother notes that the patient had a low-grade temperature on Tuesday and was feeling nauseous yesterday, all of which has resolved at present. No nasal congestion.
The patient does have cough occasionally, no discharge. The patient denies any dysphasia, no symptoms with his ears.
OBJECTIVE:
VITAL SIGNS: Weight 81 pounds, blood pressure 114/82, heart rate 80, temperature 98.8 degrees Fahrenheit and oxygen saturation 100% on room air.
HEENT: Ears: Tympanic membrane visualized with light, clear. No erythema, no effusion, nares patent, no discharge. Larynx: No tonsillar edema, no tonsillar exudate, no erythema noted.
NECK: No lymphadenopathy appreciated.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally on the anterior and posterior pulmonary fields.
ASSESSMENT AND PLAN: This is a (XX)-year-old male with past medical history of acute pharyngitis and otitis media who presents with most likely an acute viral pharyngitis with some components of a viral URI.
At this point, the mother as well as the patient was asked to take symptomatic management by taking Tylenol or ibuprofen for pain management as well as for fever, increase oral hydration, rest and monitor symptoms closely.
They will return if needed if symptoms worsen. The patient noted his understanding to these instructions.
