5/26/2020
HEENT | Completed | Shadow Health
1/2
HEENT Results | Turned In
Health Assessment - August 2017, NUR3067C
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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.
