NR 509 HEENT Documentation Shadow.pdf - HEENT Physical Assessment Assignment | Completed | Shadow Health 1 of 3

NR 509 HEENT Documentation Shadow.pdf - HEENT Physical...

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HEENT Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment Your Results Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Lifespan Review Questions Self-Reflection Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective Tina Jones is a 28 year old African American female. She came to see me with complaints of a sore and itchy throat, a runny nose, and itchy eyes for about a week. They started with no appranet cause and have been constant. There are no obvious causes. She rates the pain in her throat as mild to moderate. Her throat hurts when she swallows. Her nose runs constantly, and it is clear discharge. She has taken lozenges for her throat, as well as increased water intake, but she has not taken anything else for her eyes or her runny nose. Patient denies a cough or any recent illnesses. She claims that she has not been exposed to anything that could cause her symtpoms. She denies any changes in any other body systems. She claims that she has never been diagnosed with environmental allergies, just dust and cats. The patient does not smoke or do drugs. RoS: General: patient denies being sick recently, denies running a fever, normal energy level Head: patient denies trauma, but does have regular headaches Eyes: patient claims she has blurry vission after reading, but denies any other eye trauma. She does not wear corrective lenses. 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
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  • Fall '15
  • cough, Allergy , Heent

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