Sore Throat – Complete iHuman Case
Study With H&P, Differential Diagnosis
& SOAP Notes
Patient Case Analysis
1. Patient Information
Name: Rebecca Fields
Age: 23 years
Sex: Female
Height: 170 cm
Weight: 54.5 kg
Chief Complaint:
“Fever and sore throat.”
, 2. History Questions (Important Questions to Ask)
History of Present Illness (HPI)
When did the sore throat begin?
Was the onset sudden or gradual?
How high has the fever been?
Is the sore throat constant or intermittent?
Does swallowing worsen the pain?
Is there difficulty swallowing solids or liquids?
Any hoarseness or voice changes?
Any swollen glands in the neck?
Presence of cough or nasal congestion?
Any headache or body aches?
Any fatigue or weakness?
Any exposure to sick contacts?
Have symptoms worsened over time?
Any recent upper respiratory infections?
Any recent travel or crowded exposure?
Any rash present?
Any nausea, vomiting, or abdominal pain?
Any shortness of breath or chest discomfort?
Associated Symptoms
Fever
Chills
Fatigue
Headache
Cough
Runny nose
Difficulty swallowing
Ear pain
Neck tenderness
Body aches
Past Medical History
History of recurrent throat infections
Tonsillitis
Allergies
Asthma
Autoimmune disorders
Medication History