H_P_chart_for_Tina_Jones_82022251.docx - Document:ProviderNotes Subjective Ms. .

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Document: Provider Notes Student Documentation Model Documentation Subjective Ms. Tina Jones is a pleasant 28 year  old African Amecan female seen for  symptoms of her sore throat and  rumnny nose for the last one month.  She was seen here a month ago with  history of an infected scraped sore in  the ball of her right foot. She was put  on Antibiotics. Her wound has since  healed. For the last one week, Tina  Jones has experienced sore throat,  itchy eyes and a runny nose.She has  been using some throat drops  occasionally and some water to  relieve her symptoms and these  helped just a little. She believes her  problem may be an allergic reaction  to cats. She reports skin break down  on her face, especially arounfd her  nose and cheeks.. She denies using  any pain medication for her sore  throat. She rates her sore throat as a  5/10 in the morning and a 4/10 all the  time. She reports pain when she  swallows. She has not taken anything  for her nose problems because most  of the Over the Counter medications  HPI: Ms. Jones is a pleasant 28-y old African American woman wh presented to the clinic with  complaints of sore, itchy throat, i eyes, and runny nose for the last  week. She states that these sympt started spontaneously and have be constant in nature. She does not n any specific aggravating symptom but states that her throat pain seem be worse in the morning. She rate her throat pain as 4/10 and her thr itchiness as 5/10. She has treated  throat pain with occasional throat lozenges which has “helped a littl She states that she has some soren when swallowing, but otherwise n other associated symptoms. She s that her nose “runs all day” and is clear discharge. She has not attem any treatment for her nasal sympt She states that her eyes are consta itchy and she has not attempted a eye specific treatment. She denies cough and recent illness. She has  no exposures to sick individuals.  denies changes in her hearing, vis
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Student Documentation Model Documentation gives her drowsiness. She has been  drinking tons of water lately. Her  sister has hey fever and allergies  bothering her. No one sick otherwise  around her.  and taste. She denies fevers, chill
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  • Fall '16
  • Farah Nabilla

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