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Shadow-Health HEENT Tina Jones Questions And Answers Is your throat sore? - correct answer Reports sore throat Is your throat itchy? - correct answer Reports itchy throat Are your eyes itchy? - correct answer Reports itchy eyes Do you have a runny nose? - correct answer Reports runny nose How long has your throat been sore? - correct answer began 1 week ago When did your nose start running? - correct answer began 1 week ago When did your eyes start itching? - correct answer began 1 week ago is the throat pain constant - correct answer constant throat pain Shadow-Health HEENT Tina Jones Questions And Answers when does your throat pain feel the worst - correct answer worse in morning does it hurt when you swallo - correct answer soreness with swallowing rate throat pain on 1-10 scale - correct answer mild to moderate throat discomfort how often does your nose run - correct answer constant runny nose does your nose itch - correct answer denies do you have sinus pain - correct answer denies do you have sinus pressure - correct answer no are you sneezing - correct answer no Shadow-Health HEENT Tina Jones Questions And Answers have you taken any decongestants - correct answer denies have you taken anything for your sore throat - correct answer lozenges as treatment do the lozenges help - correct answer lozenges reduce symptoms how often do you have a lozenge - correct answer every few hours does drinking water help - correct answer water reduces symptoms have you started taking new meds - correct answer no new meds do you use an inhaler - correct answer confirms what inhaler do you use - correct answer albuterol Shadow-Health HEENT Tina Jones Questions And Answers when did you last use your inhaler - correct answer 1 week ago how often do you use your inhaler - correct answer 2 - 3 times per week how many puffs do you use - correct answer 2 - 3 puffs how many puffs are you prescribed - correct answer 2 puffs have you been exposed to any allergens - correct answer denies cat exposure do you have mold in your house - correct answer denies mold or mildew do you have dust in your house - correct answer denies dues are you allergic to anything at work - correct answer denies exposure to irritants at work Shadow-Health HEENT Tina Jones Questions And Answers how often do you change your bedding - correct answer once a week have you smoked cigs recently - correct answer denies history of cig smoking have you been exposed to secondhand smoke - correct answer denies exposure to secondhand smoke when was your last vision exam - correct answer childhood when was your last hearing exam - correct answer childhood when was your last dental visit - correct answer within the last 2 years how often did you see the dentist when you were a child - correct answer reguarly do you have dental insurance - correct answer denies Shadow-Health HEENT Tina Jones Questions And Answers where do you feel your headaches - correct answer behind her forehead how would you rate your headache on a scale of 1-10 - correct answer 3 or 4 how do you treat your headaches - correct answer Tylenol what causes your headaches - correct answer reading and studying do you have blurry vision - correct answer occasionally has your vision worsened - correct answer confirms do you have eye pain - correct answer denies do you have dry eyes - correct answer denies Shadow-Health HEENT Tina Jones Questions And Answers do you wear contacts - correct answer denies can you describe your blurry vision - correct answer fuzzy letters when do you get blurry vision - correct answer when reading for long periods how long have you been reading when your vision gets blurry - correct answer after 2+ hours of reading do you get headaches when you have blurry vision - correct answer coincide have you had ear problems - correct answer denies have you had hearing changes - correct answer denies do you have ear pain - correct answer denies Shadow-Health HEENT Tina Jones Questions And Answers do you have ear discharge - correct answer denies do you have a change in your sense of smell - correct answer denies have you had any nasal or sinus surgeries - correct answer denies have you had any nosebleeds - correct answer denies have you had problems with your mouth - correct answer denies Has your sense of taste changed? - correct answer denies have you had dry mouth recently - correct answer denies have you had any oral surgeries - correct answer denies Shadow-Health HEENT Tina Jones Questions And Answers do ear or hearing problems run in the family - correct answer denies do mouth, throat, or gland problems run in your family - correct answer denies do headaches or migraines run in your family - correct answer denies head and face - correct answer symmetric papules, pustules, or comedones excessive hair growth red, chapped nose eyes and orbital area - correct answer no visible abnormal findings moist and pink white sclera no discharge Shadow-Health HEENT Tina Jones Questions And Answers nasal cavity - correct answer pale, bluish patent clear discharge no abnormal findings right ear - correct answer pink no abnormal findings no discharge pearly gray 5:00 cone of light left ear - correct answer pink no abnormal findings no discharge pearly gray 7:00 cone of light mouth and throat - correct answer moist and pink 1+ tonsils Shadow-Health HEENT Tina Jones Questions And Answers cobblestoning edema erythemic clear discharge neck - correct answer symmetric discoloration scalp - correct answer no tenderness no abnormal findings sinuses - correct answer no tenderness temporal arteries - correct answer no thrill, 2+ no bruit carotid arteries - correct answer no thrill, 2+ no bruit Shadow-Health HEENT Tina Jones Questions And Answers 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 objective - correct answer General: Ms. Jones is a pleasant, obese Shadow-Health HEENT Tina Jones Questions And Answers 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. Shadow-Health HEENT Tina Jones Questions And Answers assessment - correct answer Allergic Rhinitis plan - correct answer 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.