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ShadowHealth HEENT Tina Jones Is your throat sore? - ANSWER Reports sore throat Is your throat itchy? - ANSWER Reports itchy throat Are your eyes itchy? - ANSWER Reports itchy eyes Do you have a runny nose? - ANSWER Reports runny nose How long has your throat been sore? - ANSWER began 1 week ago When did your nose start running? - ANSWER began 1 week ago When did your eyes start itching? - ANSWER began 1 week ago is the throat pain constant - ANSWER constant throat pain when does your throat pain feel the worst - ANSWER worse in morning does it hurt when you swallo - ANSWER soreness with swallowing rate throat pain on 1-10 scale - ANSWER mild to moderate throat discomfort how often does your nose run - ANSWER constant runny nose does your nose itch - ANSWER denies do you have sinus pain - ANSWER denies do you have sinus pressure - ANSWER no are you sneezing - ANSWER no what color is your mucus - ANSWER clear is the mucus thick - ANSWER thin mucus does your mucus have pus in it - ANSWER denies do your eyes constantly itch - ANSWER constant itching are your eyes red - ANSWER reports eye redness have you had changes in your breathing - ANSWER not affected do you have a cough - ANSWER denies do you have chest tightness - ANSWER denies have you been wheezing - ANSWER denies has your asthma worsened - ANSWER denies
do you know what is causing your symptoms - ANSWER allergy like symptoms do you think you have a cold - ANSWER no cold symptoms do you think you're having an allergic reaction - ANSWER similar symptoms to sister's hay fever have you treated your eyes with anything - ANSWER denies have you done anything for your runny nose - ANSWER denies have you taken any antihistamines - ANSWER denies have you taken any decongestants - ANSWER denies have you taken anything for your sore throat - ANSWER lozenges as treatment do the lozenges help - ANSWER lozenges reduce symptoms how often do you have a lozenge - ANSWER every few hours does drinking water help - ANSWER water reduces symptoms have you started taking new meds - ANSWER no new meds do you use an inhaler - ANSWER confirms what inhaler do you use - ANSWER albuterol when did you last use your inhaler - ANSWER 1 week ago how often do you use your inhaler - ANSWER 2 - 3 times per week how many puffs do you use - ANSWER 2 - 3 puffs how many puffs are you prescribed - ANSWER 2 puffs have you been exposed to any allergens - ANSWER denies cat exposure do you have mold in your house - ANSWER denies mold or mildew do you have dust in your house - ANSWER denies dues are you allergic to anything at work - ANSWER denies exposure to irritants at work how often do you change your bedding - ANSWER once a week have you smoked cigs recently - ANSWER denies history of cig smoking
do you have blurry vision - ANSWER occasionally has your vision worsened - ANSWER confirms do you have eye pain - ANSWER denies do you have dry eyes - ANSWER denies do you wear contacts - ANSWER denies can you describe your blurry vision - ANSWER fuzzy letters when do you get blurry vision - ANSWER when reading for long periods how long have you been reading when your vision gets blurry - ANSWER after 2+ hours of reading do you get headaches when you have blurry vision - ANSWER coincide have you had ear problems - ANSWER denies have you had hearing changes - ANSWER denies do you have ear pain - ANSWER denies do you have ear discharge - ANSWER denies do you have a change in your sense of smell - ANSWER denies have you had any nasal or sinus surgeries - ANSWER denies have you had any nosebleeds - ANSWER denies have you had problems with your mouth - ANSWER denies Has your sense of taste changed? - ANSWER denies have you had dry mouth recently - ANSWER denies have you had any oral surgeries - ANSWER denies do you have mouth pain - ANSWER denies do you have mouth sores - ANSWER denies do you have gum problems - ANSWER denies do you have tongue problems - ANSWER denies do you have jaw problems - ANSWER denies do you have any current dental problems - ANSWER denies
what dental problems have you had - ANSWER cavities as a kid do you get strep throat often - ANSWER denies do you have problems with your lymph nodes - ANSWER denies do you have a history of throat problems - ANSWER denies have you noticed any changes to your voice - ANSWER denies do you have any tonsil problems - ANSWER denies do you have any neck pain - ANSWER denies do you have family members with allergies - ANSWER sister with hay fever do vision problems run in the famiy - ANSWER denies do sinus problems run in the family - ANSWER denies do ear or hearing problems run in the family - ANSWER denies do mouth, throat, or gland problems run in your family - ANSWER denies do headaches or migraines run in your family - ANSWER denies head and face - ANSWER symmetric papules, pustules, or comedones excessive hair growth red, chapped nose eyes and orbital area - ANSWER no visible abnormal findings moist and pink white sclera no discharge nasal cavity - ANSWER pale, bluish patent clear discharge no abnormal findings right ear - ANSWER pink no abnormal findings
breath sounds - ANSWER present in all areas all areas clear no adventitious sounds pupillary reaction - ANSWER PERRL EOMs, peripheral vision - ANSWER no abnormal findings right fundal exam - ANSWER cotton wool bodies sharp disc margin left fundal exam - ANSWER no abnormalities sharp disc margin visual acuity - ANSWER right: 20/ left: 20/ weber, rinne, whisper, gag - ANSWER normal normal normal intact subjective - ANSWER 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 e objective - ANSWER 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 - ANSWER Allergic Rhinitis plan - 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
