5/26/2020 HEENT | Completed | Shadow Health
https://app.shadowhealth.com/assignment_attempts/2753746 1/2HEENT Results | Turned In
Health Assessment - August 2017, NUR3067C Return to Assignment (/assignments/140510/)
Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
Subjective
HPI. Ms T ina Jones is a 28 yo African W oman. She presented to the
clinic with complaints of sore and itchy throat, runny nose, and itchy
eyes. These symptoms started about a week ago. According to her
the symptoms began all of the sudden, and since then it persists and
constant. She takes throat drops and plenty of water to help relief the
pain of her sore throat. She denies of taking any other medications to
help with her sore throat. The sore on her throat is a little worst in the
morning and the pain is constant. She describe the pain as mild to
moderate. She states that her nose has a clear watery drainage, and
it "runs all day", and the drainage is thin and drippy . She denies of
pain, sneezing and clog nose. She does not take any medication to
relieve the symptoms of her nose. She also has an itchy eyes . She
denies of any recent illness. She report of no fever , chills or night
sweat. Denies of being diagnosed with seasonal allergy , but states
that her sister has "hay fever ." Social History: She denies of using tobacco or being exposed with
anybody who use tobacco. She denies of being exposed to allergens
or irritants. Denies of being around with sick person. Review of System: No fever , chills, fatigue, weakness , or night sweat. Head: Denies of current headache, no trauma or recent head injury ,
no dizziness or lightheadedness. Eyes: Denies of pain in the eye. She has itchy and watery eyes. her
eyes get blurry sometimes when she reads. Reported that her vision
is getting worse over the years. Ears: Denies of hearing loss or hard of hearing, no vertigo , no
drainage in the ears, no earache. Nose/Sinuses. Denies of clog nose, or pain in the nose, denies
stuffness or sneezing, no bleeding, has runny nose with clear
drainage Mouth or Throat: No hoarseness, no bleeding gums, has sore throat Respiratory: denies shortness of breathing or dif ficulty breathing, no
coughing, no wheezing , has an ashtma . She use inhaler at 2 to 3
times a week. HPI: Ms. Jones is a pleasant 28-year-old African American woma
who presented to the clinic with complaints of sore, itchy throat, i
eyes, and runny nose for the last week. She states that these
symptoms started spontaneously and have been constant in natu
She does not note any specific aggravating symptoms, but states
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 trea
her throat pain with occasional throat lozenges which has “helped
little”. She states that she has some soreness when swallowing, otherwise no other associated symptoms. She states that her no
“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
never been diagnosed with seasonal allergies, but does note tha
sister has “hay fever”. Social History: She is not aware of any environmental exposures
irritants at her job or home. She changes her sheets weekly and
denies dust/mildew at her home. She denies use of tobacco, alco
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 v
has been worsening over the past few years. She complains of b
vision after reading for extended periods. Denies increased tearin
itching prior to this past week. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earac
• 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 lym
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 wa
age 16 for asthma, last chest XR was age 16. Her current inhaler
has been her baseline of 2-3 times per week.Your Results Lab Pass (/assignment_attempts/2753746/lab_pass.p
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Lifespan
Review Questions
Self-ReflectionDocument: Provider Noteshttps://www.coursehero.com/file/62595679/HEENT-Documentation-Shadow-Health-Tina-Jonespdf/This study resource was
shared via CourseHero.com
