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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 ever had a head injury - denies do you get lightheadedness - denies how often do you have headaches - once a week how long do your headaches last - few hours how would you describe your headaches - tight and throbbing where do you feel your headaches - behind her forehead how would you rate your headache on a scale of 1- 10 - 3 or 4 how do you treat your headaches - Tylenol what causes your headaches - reading and studying do you have blurry vision - occasionally has your vision worsened - confirms do you have eye pain - denies do you have dry eyes - denies do you wear contacts - denies can you describe your blurry vision - fuzzy letters when do you get blurry vision - when reading for long periods how long have you been reading when your vision gets blurry - after 2+ hours of reading do you get headaches when you have blurry vision - coincide have you had ear problems - denies have you had hearing changes - denies do you have ear pain - denies do you have ear discharge - denies do you have a change in your sense of smell - denies
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
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/ left: 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
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 earache. • 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 lymph 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 was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week. objective - 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 - 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
