Module 06 written assignment – documentation of an assessment of
History: I recently had an episode of throat pain with difficulty swallowing and a sore throat. The symptoms began suddenly and lasted for several days. I also noticed hoarseness in my voice and an annoying tickle in my throat. There were no other associated symptoms such as fever, coughing or vomiting.
Assessment: Upon inspection of the patient’s nose, mouth, throat, and neck areas I observed mild swelling of the tonsils but no visible signs of infection or inflammation. Palpation revealed tenderness in the posterior pharynx area and lymphadenopathy was present bilaterally in the neck region with no masses felt upon palpation. No discoloration or lesions were noted on either the tongue or soft palate during examination of those areas. Auscultation revealed normal breath sounds throughout both lungs without any wheezes, rhonchi, or crackles present.
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