HEENT _ Documentation_ Shadow Health_ Tina Jones.pdf - HEENT | Completed | Shadow Health HEENT Results | Turned In Health Assessment August 2017

HEENT _ Documentation_ Shadow Health_ Tina Jones.pdf -...

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5/26/2020 HEENT | Completed | Shadow Health 1/2 HEENT Results | Turned In Health Assessment - August 2017, NUR3067C Return to Assignment (/assignments/140510/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Subjective HPI. Ms Tina Jones is a 28 yo African Woman. She presented to the clinic with complaints of sore and itchy throat, runny nose, and itchy eyes. These symptoms started about a week ago. According to her the symptoms began all of the sudden, and since then it persists and constant. She takes throat drops and plenty of water to help relief the pain of her sore throat. She denies of taking any other medications to help with her sore throat. The sore on her throat is a little worst in the morning and the pain is constant. She describe the pain as mild to moderate. She states that her nose has a clear watery drainage, and it "runs all day", and the drainage is thin and drippy. She denies of pain, sneezing and clog nose. She does not take any medication to relieve the symptoms of her nose. She also has an itchy eyes . She denies of any recent illness. She report of no fever, chills or night sweat. Denies of being diagnosed with seasonal allergy, but states that her sister has "hay fever." Social History: She denies of using tobacco or being exposed with anybody who use tobacco. She denies of being exposed to allergens or irritants. Denies of being around with sick person. Review of System: No fever, chills, fatigue, weakness , or night sweat. Head: Denies of current headache, no trauma or recent head injury, no dizziness or lightheadedness. Eyes: Denies of pain in the eye. She has itchy and watery eyes. her eyes get blurry sometimes when she reads. Reported that her vision is getting worse over the years.
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