Case
TINA JONES HEENT SHADOW HEALTH COMPLETE
- Institution
- Rivier College
TINA JONES HEENT SHADOW HEALTH COMPLETE
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By: sharpalesha • 3 year ago
By: vicbanks • 3 year ago
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Subjectivept comes in c/o sore throat and runny nose x 1 week
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 hospitalization 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. Objective
pt c/o 4/10 pain in her throat, has been using drops and tylenol otc for pain. pt also c/o headaches when reading or doing homework, hasnt had an eye exam in years. head- normocephalic, acne bilaterally to cheeks. Eyes watery with clear drainage, PERRLA, vision 20/20 in left eye and 20/30 in right. Pt reports blurry vision at times, when reading, denies glasses or contacts. Nares appear to be swollen, pt denies difficulty breathing, states that her nose has been "runny" with clear drainage. Denies hear issues, tympanic membrane intact and pink bilaterally. Mouth erythemic with cabblestoning, gag reflex intact. Visible drainage- clear. Denies dizziness, problems with gums, sinus infection hx or recent cold. pt denied any neck pain or stiffness- no palpable nodes on exam. Lung sounds clear, denies any shortness of breath or breathing difficulty.
General: Ms. Jones is a pleasant, obese 28-year-old African American 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 reveals 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. Assessment
pt assessed for sore throat and runny nose.
Allergic Rhinitis
Plan
pt to make an eye appointment for exam to get glasses. rapid strep test to be obtained as well as a throat culture for strep throat. we will wait on antibiotics until the results of the rapid come back and use the culture to verify proper sensitivities. pt to use warm salt water rinse/gargle to help decrease the pain and to continue tyleol use as needed.
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.
The pt was c/o sore throat and runny nose x 1 week which is what prompted me to exam her HEENT. I was unable to make a diagnoses based on just observation and assessment date obtained, further testing is needed to make a diagnoses of strep and order proper medications. Review of the Bates textbook and relevant chapters was read.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports sore throat
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.
Example Question:
Is your throat sore?
Finding:
Reports itchy throat
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.
Example Question:
Is your throat itchy?
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