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MEDICAL RECORD DOCUMENTATION OF ACUTE PHARYNGITIS

Name: Charles Whitcomb¹

Birth date: May 3, 1976²

Drug allergies: Hives with sulfonamides³

Immunizations: 5 DTP injections recorded⁴

Monday, September 24, 1990

CHIEF COMPLAINT: Sore throat.

HISTORY: Throat started to hurt late Friday and has worsened gradually over the weekend. Hurts to swallow. Took temperature once: 100°F last night. Nose stuffy. Thinks he has swollen glands.

PHYSICAL EXAMINATION: Fairly comfortable; complaining of throat pain.

Temperature: 101°F orally.

Tympanic membranes: clear.

Nose: No discharge but sounds stuffy.

Pharynx: Small tonsils; mildly erythematous; no exudate. Posterior soft palate and uvula mildly swollen; no petechiae.

Neck: 1.0 cm mildly tender lymph node at each mandibular angle. A few smaller anterior and a number of 0.5 cm posterior cervical nodes. Neck fully supple.