Olivia Hunt
Patient Information: J.C., 59, Male, Hispanic
S.
CC “My throat hurts real bad”
HPI: J.C. is a 59 year old Hispanic male who present to the clinic with throat and left eye pain.
He states the throat pain started three days ago after sneezing very hard. He characterizes the
pain as a constant sharp stabbing more so when swallowing. He rates the pain a 7 out of 10 on
the pain scale. He has not attempted any over the counter relief. He states he feels congested and
a “mucus build up” with associated fatigue. Patient states his left eye is tenderness started two
days ago after a family gathering where he was exposed to pink eye. His eye started producing
yellow discharge a day ago. He rates his eye pain a 4 out of 10 on pain scale characterized as an
scratchy burning sensation aggravated by blinking. Negates any alleviating factors for eye pain.
Patient denies fevers, chills, anorexia, nausea, vomiting, photophobia or diarrhea, His covid-19
exposure screening was negative.
Current Medications:
• Hydrocodone/acetaminophen: 1 tab every 4 hours PRN
• Metformin 500 XR once daily
• Simvastatin 40mg once daily
• Zestoretic 12.5mg/10mg once daily
Allergies:
• Ciproflaxin: Urticaria
PMHx: Positive for HTN, DM2, and dyslipidemia well controlled with medication. Denies past
major illnesses and is up to date on immunizations, Tdap: 1/2019, Influenza: 10/2021, Covid-19
#1- 03/2021, #2- 04/2021 booster- 09/2021. Recent lumbar fusion 11/2021 to L2-3 for DDD.
Soc Hx: J.C. is an factory worker at Cocoa- cola but is currently on FMLA due to recent spinal
fusion. He has been married to his wife for 29 years and they have two children together. He
denies using tobacco in any form. He admits to drinking alcohol socially once a week;
consuming four to five beers with friends and family. He lives with his wife in a single-family
residence with functional smoke and carbon monoxide alarms.
Fam Hx: Mother is living age 88 with dementia and HTN. Father is decreased age 69 cardiac
arrest. Two adult sons age 31 and 33 are living with no significant health history. Niece age 9
was recently diagnosis with pink eye.
, ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue. Denies near-syncope or
lightheadedness. Positive for malaise and sleep disturbances due to throat/eye pain.
HEENT:
Eyes: unilateral left eye pain with periorbital swelling and yellow discharge. Denies
bilateral visual loss, dipoplia, itching, yellowing sclerae or photophobia.
Ears: Denies hearing loss, pain, tinnitus, or drainage.
Nose: Positive for rhinorrhea and congestion. Denies loss of smell, epistaxis, or frequent
sneezing.
Throat: Positive for sore throat and painful swallowing. No history of tonsillectomy.
SKIN: Denies rash, eruption or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations
or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum. Denies recent respiratory
illness.
GASTROINTESTINAL: Denies nausea, vomiting, anorexia or diarrhea. No abdominal pain or
blood in stool.
GENITOURINARY: Denies burning on urination or hematuria.
NEUROLOGICAL: Positive for intermittent headache. Denies dizziness, syncope, paralysis,
ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Positive for anxiety. Denies history of depression.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
Patient Information: J.C., 59, Male, Hispanic
S.
CC “My throat hurts real bad”
HPI: J.C. is a 59 year old Hispanic male who present to the clinic with throat and left eye pain.
He states the throat pain started three days ago after sneezing very hard. He characterizes the
pain as a constant sharp stabbing more so when swallowing. He rates the pain a 7 out of 10 on
the pain scale. He has not attempted any over the counter relief. He states he feels congested and
a “mucus build up” with associated fatigue. Patient states his left eye is tenderness started two
days ago after a family gathering where he was exposed to pink eye. His eye started producing
yellow discharge a day ago. He rates his eye pain a 4 out of 10 on pain scale characterized as an
scratchy burning sensation aggravated by blinking. Negates any alleviating factors for eye pain.
Patient denies fevers, chills, anorexia, nausea, vomiting, photophobia or diarrhea, His covid-19
exposure screening was negative.
Current Medications:
• Hydrocodone/acetaminophen: 1 tab every 4 hours PRN
• Metformin 500 XR once daily
• Simvastatin 40mg once daily
• Zestoretic 12.5mg/10mg once daily
Allergies:
• Ciproflaxin: Urticaria
PMHx: Positive for HTN, DM2, and dyslipidemia well controlled with medication. Denies past
major illnesses and is up to date on immunizations, Tdap: 1/2019, Influenza: 10/2021, Covid-19
#1- 03/2021, #2- 04/2021 booster- 09/2021. Recent lumbar fusion 11/2021 to L2-3 for DDD.
Soc Hx: J.C. is an factory worker at Cocoa- cola but is currently on FMLA due to recent spinal
fusion. He has been married to his wife for 29 years and they have two children together. He
denies using tobacco in any form. He admits to drinking alcohol socially once a week;
consuming four to five beers with friends and family. He lives with his wife in a single-family
residence with functional smoke and carbon monoxide alarms.
Fam Hx: Mother is living age 88 with dementia and HTN. Father is decreased age 69 cardiac
arrest. Two adult sons age 31 and 33 are living with no significant health history. Niece age 9
was recently diagnosis with pink eye.
, ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue. Denies near-syncope or
lightheadedness. Positive for malaise and sleep disturbances due to throat/eye pain.
HEENT:
Eyes: unilateral left eye pain with periorbital swelling and yellow discharge. Denies
bilateral visual loss, dipoplia, itching, yellowing sclerae or photophobia.
Ears: Denies hearing loss, pain, tinnitus, or drainage.
Nose: Positive for rhinorrhea and congestion. Denies loss of smell, epistaxis, or frequent
sneezing.
Throat: Positive for sore throat and painful swallowing. No history of tonsillectomy.
SKIN: Denies rash, eruption or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations
or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum. Denies recent respiratory
illness.
GASTROINTESTINAL: Denies nausea, vomiting, anorexia or diarrhea. No abdominal pain or
blood in stool.
GENITOURINARY: Denies burning on urination or hematuria.
NEUROLOGICAL: Positive for intermittent headache. Denies dizziness, syncope, paralysis,
ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Positive for anxiety. Denies history of depression.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
