Shadow health heent tina jones

Shadow health heent tina 1. Is your throat sore?: Reports sore throat 2. Is your throat itchy?: Reports itchy throat 3. Are your eyes itchy?: Reports itchy eyes 4. Do you have a runny nose?: Reports runny nose 5. How long has your throat been sore?: began 1 week ago 6. When did your nose start running?: began 1 week ago 7. When did your eyes start itching?: began 1 week ago 8. is the throat pain constant: constant throat pain 9. when does your throat pain feel the worst: worse in morning 10. does it hurt when you swallo: soreness with swallowing 11. rate throat pain on 1-10 scale: mild to moderate throat discomfort 12. how often does your nose run: constant runny nose 13. does your nose itch: denies 14. do you have sinus pain: denies 15. do you have sinus pressure: no 16. are you sneezing: no 17. what color is your mucus: clear 18. is the mucus thick: thin mucus 19. does your mucus have pus in it: denies 20. do your eyes constantly itch: constant itching 21. are your eyes red: reports eye redness 22. have you had changes in your breathing: not affected 23. do you have a cough: denies 24. do you have chest tightness: denies 25. have you been wheezing: denies 26. has your asthma worsened: denies 27. do you know what is causing your symptoms: allergy like symptoms 28. do you think you have a cold: no cold symptoms 29. do you think you're having an allergic reaction: similar symptoms to sister's hay fever 30. have you treated your eyes with anything: denies 31. have you done anything for your runny nose: denies 32. have you taken any antihistamines: denies 33. have you taken any decongestants: denies 34. have you taken anything for your sore throat: lozenges as treatment 35. do the lozenges help: lozenges reduce symptoms 36. how often do you have a lozenge: every few hours 37. does drinking water help: water reduces symptoms 38. have you started taking new meds: no new meds 39. do you use an inhaler: confirms 40. what inhaler do you use: albuterol 41. when did you last use your inhaler: 1 week ago 42. how often do you use your inhaler: 2 - 3 times per week 43. how many puffs do you use: 2 - 3 puffs 44. how many puffs are you prescribed: 2 puffs 45. have you been exposed to any allergens: denies cat exposure 46. do you have mold in your house: denies mold or mildew 47. do you have dust in your house: denies dues 48. are you allergic to anything at work: denies exposure to irritants at work 49. how often do you change your bedding: once a week 50. have you smoked cigs recently: denies history of cig smoking 51. have you been exposed to secondhand smoke: denies exposure to second- hand smoke 52. when was your last vision exam: childhood 53. when was your last hearing exam: childhood 54. when was your last dental visit: within the last 2 years 55. how often did you see the dentist when you were a child: reguarly 56. do you have dental insurance: denies 57. do you have vision insurance: denies 58. are you allergic to cats: confirms 59. are you allergic to dust: confirms 60. do you have seasonal allergies: denies 61. have you been sick recently: denies 62. do you have chills: denies 63. do you have fever: denies 64. have you felt fatigued: low energy level 65. have you felt nauseous: denies nausea or vomiting 66. do you ever get headaches: occasional headaches 67. do you have a headache currently: denies 68. have you ever had a head injury: denies 69. do you get lightheadedness: denies 70. how often do you have headaches: once a week 71. how long do your headaches last: few hours 72. how would you describe your headaches: tight and throbbing 73. where do you feel your headaches: behind her forehead 74. how would you rate your headache on a scale of 1-10: 3 or 4 75. how do you treat your headaches: Tylenol 76. what causes your headaches: reading and studying 77. do you have blurry vision: occasionally 78. has your vision worsened: confirms 79. do you have eye pain: denies 80. do you have dry eyes: denies 81. do you wear contacts: denies 82. can you describe your blurry vision: fuzzy letters 83. when do you get blurry vision: when reading for long periods 84. how long have you been reading when your vision gets blurry: after 2+ hours of reading 85. do you get headaches when you have blurry vision: coincide 86. have you had ear problems: denies 87. have you had hearing changes: denies 88. do you have ear pain: denies 89. do you have ear discharge: denies 90. do you have a change in your sense of smell: denies 91. have you had any nasal or sinus surgeries: denies 92. have you had any nosebleeds: denies 93. have you had problems with your mouth: denies 94. Has your sense of taste changed?: denies 95. have you had dry mouth recently: denies 96. have you had any oral surgeries: denies 97. do you have mouth pain: denies 98. do you have mouth sores: denies 99. do you have gum problems: denies 100. do you have tongue problems: denies 101. do you have jaw problems: denies 102. do you have any current dental problems: denies 103. what dental problems have you had: cavities as a kid 104. do you get strep throat often: denies 105. do you have problems with your lymph nodes: denies 106. do you have a history of throat problems: denies 107. have you noticed any changes to your voice: denies 108. do you have any tonsil problems: denies 109. do you have any neck pain: denies 110. do you have family members with allergies: sister with hay fever 111. do vision problems run in the famiy: denies 112. do sinus problems run in the family: denies 113. do ear or hearing problems run in the family: denies 114. do mouth, throat, or gland problems run in your family: denies 115. do headaches or migraines run in your family: denies 116. head and face: symmetric papules, pustules, or comedones excessive hair growth red, chapped nose 117. eyes and orbital area: no visible abnormal findings moist and pink white sclera no discharge 118. nasal cavity: pale, bluish patent clear discharge no abnormal findings 119. right ear: pink no abnormal findings no discharge pearly gray 5:00 cone of light 120. left ear: pink no abnormal findings no discharge pearly gray 7:00 cone of light 121. mouth and throat: moist and pink 1+ tonsils cobblestoning edema erythemic clear discharge 122. neck: symmetric discoloration 123. scalp: no tenderness no abnormal findings 124. sinuses: no tenderness 125. temporal arteries: no thrill, 2+ no bruit 126. carotid arteries: no thrill, 2+ no bruit 127. jaw: no abnormal findings 128. lymph nodes: no palpable nodes 129. thyroid gland: not palpable no tenderness 130. breath sounds: present in all areas all areas clear no adventitious sounds 131. pupillary reaction: PERRL 132. EOMs, peripheral vision: no abnormal findings 133. right fundal exam: cotton wool bodies sharp disc margin 134. left fundal exam: no abnormalities sharp disc margin 135. visual acuity: right: 20/40 left: 20/20 136. weber, rinne, whisper, gag: normal normal normal intact 137. subjective: HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of sore, itchy throat, itchy eyes, and runny nose for the last week. She states that these symptoms started spontaneously and have been constant in nature. She does not note any specific aggravating symptoms, but states that her throat pain seems to be worse in the morning. She rates her throat pain as 4/10 and her throat itchiness as 5/10. She has treated her throat pain with occasional throat lozenges which has "helped a little". She states that she has some soreness when swallowing, but otherwise no other associated symptoms. She states that her nose "runs all day" and is clear discharge. She has not attempted any treatment for her nasal symptoms. She states that her eyes are constantly itchy and she has not attempted any eye specific treatment. She denies cough and recent illness. She has had no exposures to sick individuals. She denies changes in her hearing, vision, and taste. She denies fevers, chills, and night sweats. She has never been diagnosed with seasonal allergies, but does note that her sister has "hay fever". Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history of trauma or headaches. • Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching prior to this past week. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea prior to this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth. No sore throat prior to this episode. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospital- ization was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week. 138. objective: General: Ms. Jones is a pleasant, obese 28-year-old African Amer- ican woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left fundoscopic exam re- veals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Rinne, Weber, and Whisper tests normal bilaterally. • Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain with palpation of frontal or maxillary sinuses. • Mouth/Throat: Moist buccal mucosa, no wounds visualized. Adequate dental hygiene. Uvula midline. Tonsils 1+ and without evidence of inflammation. Posterior pharynx is slightly erythematous with mild cobblestoning. •Neck: No cervical, infraclavicular lymphadenopathy. Thyroid is smooth without nodules or goiter. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation without wheezes, crackles, or cough. 139. assessment: Allergic Rhinitis 140. plan: Encourage Ms. Jones to continue to monitor symptoms and log her episodes of allergic symptoms with associated factors and bring log to next visit. • Initiate trial of loratadine (Claritin) 10 mg by mouth daily. • Encourage to increase intake of water and other fluids and educate on frequent handwashing. • Educate on avoidance of triggers and known allergens • Educate Ms. Jones on when to seek care including episodes of uncontrollable epistaxis, worsening headache, or fever. • Revisit clinic in 2-4 weeks for follow up and evaluation.