GENERAL DATA: AA 21 year old, Male, Filipino, Roman Catholic, born on May 23, 1999, in Caloocan City,

currently residing at Bagong Barrio, Caloocan City admitted for the first time at MCU Hospital

CHIEF COMPLAINT: Difficulty swallowing

HISTORY OF PRESENT ILLNESS:

1 week prior to consult, patient experienced throat itchiness later associated with throat pain graded at
2/10. There were no associated signs and symptoms such as cough, cold, fever, or difficulty in
swallowing. No consult was done, no medications taken

3 days prior, throat pain became more severe, now 5/10, with associated undocumented high-grade
fever. Patient took 500mg tablet Paracetamol which provided lysis of the fever, but not the throat pain.

Few hours prior, throat pain now 7/10, still with undocumented intermittent fever, now with associated
difficulty in swallowing, thus sought consult.

PAST MEDICAL HISTORY: Had the usual childhood illness like measles, mumps and chicken pox No
known allergies to food nor medications No previous history of hospitalizations, pulmonary tuberculosis,
hypertension, diabetes mellitus, and asthma. No surgery or history of transfusion.

FAMILY HISTORY: Father: apparently well and works as a security guard. Mother is apparently well No
other heredo-familial diseases like Bronchial Asthma, Lung Disease, Thyroid disease, and Liver Disease.

PERSONAL AND SOCIAL HISTORY: Non-smoker, non-alcoholic beverage drinker. Patient is a college
student. Currently living with his parents. He is single and denies illicit drug use or STIs. He has a
girlfriend but denies sexual contact. He is the youngest of three siblings

REVIEW OF SYSTEMS

Constitutional symptoms: (-) weight loss; (-) easy fatigability, (-) chills Skin: (-) excessive sweating, (-)
cyanosis, (-) pallor, (-) jaundice, (-) erythema Head: (-) headache, (-) dizziness, (-) vertigo

Eyes: (-) used of eye glasses (-) double vision (-) excessive lacrimation (-) photophobia

Ears: (-) earache, (-) deafness, (-) tinnitus, (-) ear discharge

Mouth & throat: (-) toothache, (-) gum bleeding, (-) disturbance in taste, (+) sore throat, (+) hoarseness

Neck: (-) nape pain, (-) neck vein engorgement

Respiratory: (-) hemoptysis, (-) chest pain, (-) cough

Cardiovascular: (-) palpitations, (-) syncope, (-) easy fatigability

Gastrointestinal: (-) nausea, (-) dysphagia, (-) diarrhea, (-) constipation

Genitourinary: (-) dysuria, (-) urinary frequency, (-) urgency (-) hematuria Extremities:

Nervous: (-) headache, (-) vertigo, (-) syncope, (-) numbness, (-) loss of memory, (-) loss of consciousness

Hematologic: (-) pallor, (-) easy bruising, (-) bleeding tendency

Endocrine: (-) intolerance to heat & cold, (-) polydipsia (-) polyuria
PHYSICAL EXAMINATION: coherent, not in cardiorespiratory distress, febrile. GCS 15 (E4V5M6) oriented
to time place and person. Looks appropriate for age, with the following vital signs: BP: 110/80 mmHg CR:
98 bpm RR: 21 cpm Temperature: 38.1

HEENT: Auricles are symmetrical. Patent, no discharge, external auditory canals are not hyperemic,
tympanic membrane is intact cone of light, no perforation. Nose is symmetrical, no lesion, no flaring of
ala nasi; nasal septum is straight, midline and intact. Lips are pink, moist, symmetrical. Buccal mucosa is
pink, smooth, no swelling, no lesion. Gums are pink, no lesion. Tongue is normal in size, shape, pink,
with rough papillae, symmetrical, mobile with no lesions and tremors. Complete set of teeth. Hard
palate and soft palate is pink with no lesions. Uvula is hyperemic and midline. Posterior pharyngeal walls
and tonsils are hyperemic, with the tonsils enlarged bilaterally with exudates. Normal in size,
symmetrical, no visible mass, swelling nor deformity, normal mobility, normal muscle tone, no
tenderness. Trachea in the midline. Palpable tender lymph nodes at the level IIA bilaterally. Thyroid
gland not visible, not palpable. No neck vein engorgement

THORAX and LUNGS: Chest is fair; no visible mass, no dilated superficial vessels, thorax is elliptical;
symmetrical chest expansion, no retractions, vesicular breath sounds upon auscultation.

HEART: Precordium is adynamic, with normal rate and regular rhythm, no murmur. Apex beat located at
the 5th ICS, left midclavicular line. Noted distinct S1 and S2. The carotid arteries have strong equal
pulsations. No thrills nor heaves noted.

ABDOMEN: On inspection, abdomen is fair, no lesions & scars, globular, inverted umbilicus, no dilated
superficial blood vessels, no abnormal pulsations, no visible peristalsis and no mass. On auscultation,
normoactive bowel sounds, no bruit heard over the epigastrium, right and left paraumbilical area. On
percussion, abdomen is tympanitic at all quadrants. On palpation, no tenderness noted, no
organomegaly, no palpable masses

RECTAL EXAMINATION: No fissure no skin tag, good sphincter tone, no palpable masses, brownish fecal
material upon withdrawal of examining finger

EXTREMITIES: full and equal pulses, no edema.

NEUROLOGIC EXAMINATION:
Cerebrum: Patient is GCS 15 (E4V5M6). Oriented to time, place, and person. Responds appropriately to
verbal, tactile, and painful stimuli; Memory is intact. Appropriate mood and affect.
Cerebellum: Can perform rapid alternating movements and finger to nose test

Cranial Nerves
CN I: can identify the scent of coffee on both nostrils
CN II: pupils are 2 – 3 mm equally reactive to light and with accommodation, positive red-orange reflex,
no visual field defect
CN III, IV, VI: intact extra ocular muscles, can move eyes on all quadrants
CN V: can clench jaw and move it from side to side
CN VII: can elevate both eyebrows, can close both eyes completely, can puff cheeks, can wrinkle
forehead, no asymmetry noted upon smiling or frowning
CN VIII: intact gross hearing
CN IX, X: uvula is at the midline
CN XI: can elevate shoulders equally and can turn head on both sides against resistance
CN XII: tongue is at the midline

Meningeal irritation: (-) Nuchal rigidity, (-) Brudzinski sign, (-) Kernig’s sign
Pathologic Reflexes: (-) Babinski, (-) Ankle clonus