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ShadowHealth HEENT Tina Jones., Exams of Nursing

ShadowHealth HEENT Tina Jones.

Typology: Exams

2023/2024

Available from 03/06/2024

johnNice
johnNice 🇺🇸

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Download ShadowHealth HEENT Tina Jones. and more Exams Nursing in PDF only on Docsity! ShadowHealth HEENT Tina Jones Is your throat sore? - Reports sore throat Is your throat itchy? - Reports itchy throat Are your eyes itchy? - Reports itchy eyes Do you have a runny nose? - Reports runny nose How long has your throat been sore? - began 1 week ago When did your nose start running? - began 1 week ago When did your eyes start itching? - began 1 week ago is the throat pain constant - constant throat pain when does your throat pain feel the worst - worse in morning does it hurt when you swallo - soreness with swallowing rate throat pain on 1-10 scale - mild to moderate throat discomfort how often does your nose run - constant runny nose does your nose itch - denies do you have sinus pain - denies do you have sinus pressure - no are you sneezing - no what color is your mucus - clear is the mucus thick - thin mucus does your mucus have pus in it - denies do your eyes constantly itch - constant itching are your eyes red - reports eye redness have you had changes in your breathing - not affected do you have a cough - denies do you have chest tightness - denies have you been wheezing - denies has your asthma worsened - denies do you know what is causing your symptoms - allergy like symptoms do you think you have a cold - no cold symptoms do you think you're having an allergic reaction - similar symptoms to sister's hay fever have you treated your eyes with anything - denies have you done anything for your runny nose - denies have you taken any antihistamines - denies have you taken any decongestants - denies have you taken anything for your sore throat - lozenges as treatment do the lozenges help - lozenges reduce symptoms how often do you have a lozenge - every few hours does drinking water help - water reduces symptoms have you started taking new meds - no new meds do you use an inhaler - confirms what inhaler do you use - albuterol when did you last use your inhaler - 1 week ago how often do you use your inhaler - 2 - 3 times per week how many puffs do you use - 2 - 3 puffs how many puffs are you prescribed - 2 puffs have you had any nasal or sinus surgeries - denies have you had any nosebleeds - denies have you had problems with your mouth - denies Has your sense of taste changed? - denies have you had dry mouth recently - denies have you had any oral surgeries - denies 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 dental problems - denies what dental problems have you had - cavities as a kid do you get strep throat often - denies do you have problems with your lymph nodes - denies do you have a history of throat problems - denies have you noticed any changes to your voice - denies do you have any tonsil problems - denies do you have any neck pain - denies do you have family members with allergies - sister with hay fever do vision problems run in the famiy - denies do sinus problems run in the family - denies do ear or hearing problems run in the family - denies do mouth, throat, or gland problems run in your family - denies do headaches or migraines run in your family - denies head and face - symmetric papules, pustules, or comedones excessive hair growth red, chapped nose eyes and orbital area - no visible abnormal findings moist and pink white sclera no discharge nasal cavity - pale, bluish patent clear discharge no abnormal findings right ear - 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 reaction - PERRL EOMs, peripheral vision - no abnormal findings right fundal exam - cotton wool bodies sharp disc margin left fundal exam - no abnormalities sharp disc margin visual acuity - right: 20/40 left: 20/20 weber, rinne, whisper, gag - normal 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, 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