Sam is a 24yo gentleman who presents to clinic today with chief complaint of sore throat since this morning. He awoke with pain in his throat which has been persistent. He rates his pain at a 2 out of 10. He is able to produce some phlegm, which is mostly yellow. He denies any cough, headache, nausea, vomiting, or fever.
On physical exam today, Sam is a healthy-appearing male with blood pressure of 122/84, heart rate of 72, and weight of 122 pounds, which is stable for him. He is afebrile with temperature of 98.2 °F. His oropharynx is slightly erythematous with no visible exudate. He has no nasal discharge and his nasopharynx is clear. There is some tenderness to palpation of the trachea, which is midline and mobile.
IMPRESSION & PLAN:
Sam's sore throat is likely viral in nature. I recommend that he gargle with warm salt water three times each day and suck on throat lozenges when he notices the pain. This clinic is really just Sam's bedroom and does not carry the Rapid Strep Test, so I cannot diagnose whether or not this is strep throat. Even if it were, I am not a real doctor, so I cannot write a penicillin prescription. FML.
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