CHIEF COMPLAINT: Sore throat and fever.
SUBJECTIVE: Starting Thursday last week, the patient had an acute sore throat as well as a mild fever. The fever was at its greatest on Saturday and the temperature was 102 degrees. Approximately Thursday last week, the patient came in for evaluation and was given penicillin for presumed strep throat. The patient did not feel any better on Saturday and so he presented to the emergency department for further evaluation.
In the emergency department, he was changed from penicillin to azithromycin. He was also given nystatin for thrush. He took those medications through today’s visit. Last night and this morning, the patient was feeling that his sore throat and his temperature are much improved. He has continued to take his medication as ordered. His appetite has been a little bit diminished, but he has been drinking adequate fluid to void about 5-7 times per day.
He is also concerned about 3 lesions in his mouth that have come up in the last 3 days. Of note, he is a type 1 diabetic and reports his sugars have been in control but he is concerned about an approximately 8 pound weight loss since March of this year. He is unsure what might be causing this.
OBJECTIVE:
VITAL SIGNS: Reviewed and reconciled.
GENERAL: The patient is a (XX)-year-old male in no acute distress.
HEENT: Normocephalic and atraumatic. Hearing and vision are grossly intact. Pupils are equal, round, reactive to light and accommodation. Sclerae white. Conjunctivae pink. Posterior pharynx is erythematous. Tonsils: Three white plaques with erythematous base measuring 2-5 mm across, located on right soft palate, sublingually, and lower lip. Thin line of erythema along the gumline, top and bottom. Tongue is mildly white. No cervical lymphadenopathy. Moves neck in all directions without difficulty.
LUNGS: Even unlabored respirations clear to auscultation bilaterally.
HEART: Regular rate and rhythm.
ASSESSMENT AND PLAN: This is a (XX)-year-old male who comes in with complaints of sore throat, fever and lesions in the mouth. His sore throat and fever are resolving, and the discomfort in his mouth is improving. The lesions are herpes simplex and will resolve without any intervention.
He should continue to take his azithromycin and his nystatin to completion. For any discomfort, he can take ibuprofen or acetaminophen in over-the-counter dosing. He should expect that his symptoms continue to resolve over the next 5-7 days.
We would like the patient to come back for evaluation in approximately 1 month. This is to better understand if the weight loss is related to this acute illness or if it is related to a long-term issue. The patient is to call back with any further questions or concerns. The patient verbalized understanding of this plan and agrees.
