Chapter 5: The Lymphatic and Immune Systems | Sidney O'Brian's Chart Note

CHART NOTE

Patient Name: O'Brian, Sidney
ID Number: SO4423
Examination Date: September 16, 20xx

SUBJECTIVE
Sidney is a 17-year-old who presents with a 7-day history of chills, sore throat, fatigue, fever, and headache. Over the weekend her symptoms have worsened and she is extremely tired. She states that she "shared a straw" with a friend when they were at the mall 2 weeks ago and now her friend is also sick.

OBJECTIVE
BP 120/76, temperature 102.4, respiratory rate 23, pulse 72. Lungs are clear. Lymph nodes are swollen. Tonsils are enlarged and have a whitish-yellow covering.

ASSESSMENT
Cervical lymphadenopathy. Mononucleosis test performed in the office is positive.

PLAN
The patient should drink plenty of fluids, gargle with warm salt water to ease sore throat pain, and get plenty of rest. She may take acetaminophen or ibuprofen for fever and discomfort.