Name: Brian Davis

21 year old Male patient

Medical history:
*Current complaints- sore
throat and fatigue since 2
weeks , left upper quadrant pain
since yesterday which does not
have triggering factors with
decreased appetite and weight
loss and pain near the neck
* Past medical history-
Gonorrhea 4 months ago for
which he took Antibiotics. No
history of allergy
* Current medications-
Tylenol

Social history:
 * Drinks alcohol on weekends
* Smokes 1pack of cigarette
a day since he was 15 years old

Sexual history:
* Had 3 sexual partners
 * Had sex with both men and
women

Family history:
No other history, they are
healthy

Physical examination:
* BP- 120/80 mmHg
* RR- 15/min
* HR- 75/min
* Temp- 99.5°F

Palpation-
* Abdomen- soft and
distended
*Left upper quadrant
tenderness
* Cervical lymphadenopathy
Further laboratory and diagnosic
tests-
CBC
Throat swab
CT scan of abdomen
Urine analysis
Differential diagnosis:
Viral infection
GERD
Infectious mononucleosis
Acute HIV
Gonorrhea ( remission)

Diagnosis- Infectious
mononucleosis

Treatment- Drinking plenty of

fluids, rest and having a
healthy diet
Acyclovir