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ShadowHealth HEENT Tina Jones Actual Updated Questions And Answers
- Is your throat sore?
- Is your throat itchy?
- Are your eyes itchy?
- Do you have a runny nose?
- How long has your throat been sore?
- When did your nose start run- ning?
- When did your eyes start itch- ing?
- is the throat pain constant
- when does your throat pain feel the worst Reports sore throat Reports itchy throat Reports itchy eyes Reports runny nose began 1 week ago began 1 week ago began 1 week ago constant throat pain worse in morning
- does it hurt when soreness with swallowing you swallo
- rate throat pain on 1 - 10 scale
- how often does your nose run
- does your nose itch
- do you have si- nus pain
- do you have si- nus pressure mild to moderate throat discomfort constant runny nose denies denies no
- are you sneezing no
- what color is your clear mucus
- is the mucus thick
- does your mucus have pus in it thin mucus denies
- do your eyes con- constant itching stantly itch
- are your eyes red reports eye redness
- have you had changes in your breathing not affected
- have you tak- en any deconges- tants
- have you taken anything for your sore throat
- do the lozenges help denies lozenges as treatment lozenges reduce symptoms
- how often do you every few hours have a lozenge
- does drinking water help
- have you started taking new meds
- do you use an in- haler
- what inhaler do you use water reduces symptoms no new meds confirms albuterol
- when did you last 1 week ago use your inhaler
- how often do you 2 - 3 times per week use your inhaler
- 2 - 3 puffs
how many puffs do you use
- how many puffs are you pre- scribed
- have you been exposed to any allergens
- do you have mold in your house
- do you have dust in your house
- are you allergic to anything at work 2 puffs denies cat exposure denies mold or mildew denies dues denies exposure to irritants at work
- how often do you once a week change your bed- ding
- have you smoked denies history of cig smoking cigs recently
- have you been exposed to sec- ondhand smoke denies exposure to secondhand smoke
- childhood
- do you have fever denies
- have you felt fa- tigued
- have you felt nauseous
- do you ever get headaches
- do you have a headache cur- rently
- have you ever had a head injury
- do you get light- headedness low energy level denies nausea or vomiting occasional headaches denies denies denies
- how often do you once a week have headaches
- how long do your few hours headaches last
- how would you describe your headaches
- where do you feel your headaches tight and throbbing behind her forehead
- how would you rate your headache on a scale of 1 - 10
- how do you treat your headaches 3 or 4 Tylenol
- what causes your reading and studying headaches
- do you have blur- occasionally ry vision
- has your vision worsened
- do you have eye pain
- do you have dry eyes
- do you wear con- tacts
- can you describe your blurry vision
- when do you get blurry vision confirms denies denies denies fuzzy letters when reading for long periods
- after 2+ hours of reading
have you had problems with your mouth
- Has your sense of denies taste changed?
- have you had dry mouth recently denies
- have you had any denies oral surgeries
- do you have mouth pain denies
- do you have mouth sores denies
- do you have gum problems denies
- do you have tongue problems denies
- do you have jaw problems denies
- do you have any current den- tal problems denies
- cavities as a kid
what dental problems have you had
- do you get strep throat often
- do you have problems with your lymph nodes
- do you have a history of throat problems
- have you noticed any changes to your voice
- do you have any tonsil problems
- do you have any neck pain denies denies denies denies denies denies
- do you have fam- sister with hay fever ily members with allergies
- do vision prob- lems run in the famiy denies
pink no abnormal findings no discharge pearly gray 5:00 cone of light
- left ear pink no abnormal findings no discharge pearly gray 7:00 cone of light
- mouth and throat moist and pink 1+ tonsils cobblestoning edema erythemic clear discharge
- neck symmetric discoloration
- scalp no tenderness no abnormal findings
- (^) sinuses no tenderness
- temporal arteries no thrill, 2+ no bruit
- carotid arteries no thrill, 2+ no bruit
- jaw no abnormal findings
- lymph nodes no palpable nodes
- thyroid gland not palpable no tenderness
- breath sounds present in all areas all areas clear no adventitious sounds
- pupillary reac- PERRL tion
- EOMs, peripheral no abnormal findings vision
- right fundal cotton wool bodies exam sharp disc margin
- left fundal exam no abnormalities sharp disc margin
- visual acuity right: 20/ left: 20/
- weber, rinne, normal whisper, gag normal normal intact
- 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,
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 mar- gins, 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, infraclavicu- lar 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 Allergic Rhinitis
- 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.
