Exam (elaborations) (SOAP NOTE) NR511 MARY 40 YO FEMALE CAUCASIAN (CC Sore Throat)

(SOAP NOTE) NR511 MARY 40 YO FEMALE CAUCASIAN (CC Sore Throat) Patient Information: Mary, 40 yr old F, Caucasian S: CC: Sore Throat HPI: Patient c/o sore throat that began yesterday and is worse when she swallows. She states she has not eaten or drank anything because it hurts too much. She states it feels like something sharp is in her throat when she swallows. Patient also reports a new onset of fatigue and chills. Patient is currently not taking anything for the pain. She reports the pain 4/5 when swallowing. Current Medications: Daily multivitamin, B complex supplement. Allergies: NKDA. PMHx: Denies any past illness, injuries or surgeries. Hospitalized x2 for childbirth. Soc Hx: Married, drinks alcohol socially, denies tobacco or illicit drug use. Fam Hx: Mary lives with her husband, her parents and her 4 children. Her father and husband both smoke but she states they do not smoke "in the house". Mary also states they have 2 dogs and a cat. ROS: Constitutional: Denies weight loss. Reports new onset of fatigue and chills. HEENT: Denies any headaches and visual changes, wears contact lenses. No reported hearing loss, or ringing in the ears. No reported nasal congestion or discharge. Reports sore throat and difficulty swallowing, denies cough and hoarseness. Cardiovascular: Denies chest pain, palpitations and dizziness. Respiratory: Denies cough, difficulty breathing, and shortness of breath or wheezing. Gastrointestinal: No reported bowel problems. No heartburn or indigestion reported. Lymphatics: Denies any enlarged lymph nodes. O: Vital signs: BP 128/72, Temp 101.2, P 100, RR 14 Height: 5' 4" Weight: 149 BMI: 25.6 (overweight) General: Alert, orientated, and cooperative.