Fever and Sore Throat in a 23-Year-Old Female: A Comprehensive i-Human Clinical Case Analysis 2026

Fever and Sore Throat in a
23-Year-Old Female: A
Comprehensive i-Human
Clinical Case Analysis 2026




COMPREHENSIVE SOAP NOTE
Patient Name: Jenna James
Age: 23 years
Sex: Female
Weight: 54.5 kg (120 lbs)
Encounter Type: Outpatient Clinic Visit
Chief Complaint (CC):
“I have had a sore throat and fever for the last three days.”

, S – Subjective
History of Present Illness (HPI)

Jenna James is a 23-year-old female who presents with a 3-day history of sore throat and
fever. The sore throat is constant and described as sharp and painful, especially with
swallowing. She reports associated fatigue and malaise. She has tried acetaminophen with
minimal relief. She denies cough, shortness of breath, chest pain, nausea, vomiting, or
rhinorrhea. No known sick contacts.

 Onset: 3 days ago
 Location: Throat
 Duration: Constant
 Character: Painful, scratchy
 Associated symptoms: Fever, fatigue
 Aggravating factors: Swallowing
 Relieving factors: Minimal relief with acetaminophen
 Severity: 7/10



Past Medical History (PMH)

 No chronic medical conditions

Past Surgical History (PSH)

 Denies

Medications

 Acetaminophen PRN for fever

Allergies

 No known drug allergies (NKDA)

Family History

 Non-contributory

Social History

 Non-smoker
 Denies alcohol or illicit drug use
 College student