The patient is a 40 year old man of a white origin.
Source and reliability: Self, wife and mother.
Chief complaint: The patient complaints of sore throat and fiver.
HPI: Mr. James complains of worsening sore throat and fiver since yesterday. He has never had
such symptoms before. He notes that she does not have difficulty in swallowing but he notes that
swallowing makes the pain worse. There is nothing that makes it better. There is no sensation of
chocking or dysphagia or SOB. He is also experiencing fever that is making him sick.
Hospitalization: the patient notes that she has never been hospitalized.
Immunization: he has undergone all the immunization strategies that have been
recommended the ministry of health.
Health maintenance; none
Family history: Paternal grandmother died of diabetes aged 89. The maternal grandmother is
still alive and healthy. The paternal and the maternal grandfather are both alive and healthy.
Social history: He comes from a closely knit family full of love and care.
Review of symptoms: complains of fiver and sore throat. He does not present other symptoms.
HEENT: Sore throat and fiver.
Height: 57” Weight: 82 lbs. BMI: 18.5 (Normal)
Temperature: 35.5 ⁰C, Blood Pressure: 105/70, Pulse: 86, Respiration: 18
General: 40 y/o female, slightly fatigued, participates in the medical examination
appropriately. interactive and answers appropriately
HEENT: He has a good conjugate gaze, he does not have any sinus pain or pressure,
TMs normal bilaterally;
Neck: bilateral tenderness, supple, .no masses noted.
Lungs: Higher breathing rate.
Rapid Strep Antigen Test: (-) negative.
Influenza H1N5 is suspected in this case. The patients with influenza have a sore
throat and fiver.
Sputum and blood test showed presence of influenza virus in the system.
i. Diagnostic: Will be done through observation, listening to the patient then
getting some information from the mother and wife.
ii. Pharmacological: A full dose of oseltamivir (Tamiflu),
iii. Non pharmacological: Good diet full of vitamins.
iv. Education: educate the patient against staying inn crowded places because he
Zhou, B., Zhong, N., & Guan, Y. (2007). Treatment with convalescent plasma for influenza A
(H5N1) infection. New England Journal of Medicine, 357(14), 1450-1451.