NR 601 Week 1 iHuman Practice Case - William Montgomery

Problem Statement by Kimberley Alvey on case William Montgomery WM is an 18 year old male with chief complaints of cough, sore throat and fever. Reports fever, chills, swollen neck glands and myalgia. Denies otalgia or nasal drainage. History of asthma. Positive objective physical exam findings include erythematous posterior pharynx, bilateral anterior cervical adenopathy node enlargement with tenderness. pertinent negatives objective findings include tympanic membranes without erythema, bulging or middle ear effusion, and clear lung sounds in all lungs Attempt: 3731496 Report generated on 11/8/2025, 8:31:50 PM America/Denver Electronic Health Record by Kimberley Alvey on case William Montgomery History of Present Illness Category Data entered by Kimberley Alvey Reason for Encounter cough, fever, sore throat for 4 days History of present illness O-4 days L-throat and headache D-constant C-fever 101 in the office today, sore throat, fatigue A-coughing R-ibuprofen, warm liquids T-rest, ibuprofen S-throat feels like "razor blades" Past Medical History Category Data entered by Kimberley Alvey Past Medical History childhood asthma, no attacks in many years. Hospitalizations / Surgeries none Medications Category Data entered by Kimberley Alvey Medications ibuprofen as needed Allergies Category Data entered by Kimberley Alvey Allergies no allergies Preventive Health Category Data entered by Kimberley Alvey Preventive health no Flu vaccine received-was supposed to get while on campus but did not, COVID vaccination received, but no booster Physical Exams Category Data entered by Kimberley Alvey General awake, alert and oriented times 4, in mild distress, well nourished, well developed male, appropriate height and weight. Patient is polite and cooperative and appears stated age. Skin warm dry and intact without rashes or lesions, appropriate color for ethnicity, nailbeds pink without cyanosis or clubbing HEENT / Neck HEAD-normocephalic and atraumatic, conjunctivaa pink and witho0ut drainage or redness bilaterally, PERRLA 3mm bilaterally, EARS- external ears canals are non-tender without swelling or erythema, no discharge, bilateral typanic membranes are shiny and grey, no discharge, SINUSES-no frontal or maxilarry pain on palpation. THROAT-erythmatous posterior pharynx, NECK- supple with bilateral anterior cervical lymph node enlargement and tenderness. Full ROM without difficulty, trachea is midline. Cardiovascular regular rate and rhythm, no murmurs, rubs or gallops, S1 and S2 present. carotic pulses 2+ without bruits bilaterally, no JVD, extremities withhout swelling, cap refill less than 3 secs in all extremities. Chest / Respiratory chest is symmetric and without deformity, chest wall is non tender. even and nonlabored respirations without signs of respiratory distress, lungs are clear without rales, rhonchi, or wheeze, normal resonance upon percussion of all lung fields Abdomen soft symmetric and non tender, bowel sounds active in all quadrants. Genitourinary / Rectal not tested Musculoskeletal / Osteopathic curvature of the cervical, thoracic and lunbar spine are within normal limits. Structural Examination Full ROM without discomfort. Neurologic awake, alert and oriented times 4, all cranial nerves intact, memory intact, cerebellar function intact Psychiatric appropriate mood and affect, good judgement and insight Lymphatic bilateral anterior cervical adenopathy node enlargement and tendern4ess, no other lymph node enlargement. Attempt: 3731496 Report generated on 11/8/2025, 8:31:50 PM