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8/16/2020HEENT | Completed | Shadow Health1/2HEENT Results | Turned InAdvanced Health Assessment - July 2020, NURP 500/530Return to Assignment(/assignments/356673/)Documentation / Electronic Health RecordDocument: Provider NotesStudent DocumentationModel DocumentationSubjectiveMrs Jones is a 28 year old afterican american women who ispresented to the clinic with compliants of sore, itchy throat andrunny noes for the past week. She states the throat pain is bad andrates it a 4/10. She states that these symptoms startedspontaneously and have been constant and nature. She does notknow any specific aggravating symptoms, but states that her throatpain seems to be worse in the morning. She states that she hastreated her throat pain with occasional throat lozenges which has"help a little". The patient mentions that it hurts to swallow and thather eyes are itchy. She denies taking anything to stop her nasalirritation and itchy eyes. She states that her nose "runs all day" andis clear in discharge. she has not attempted any treatment for hernasal symptoms. Patient denies exposure to sick individuals, deniessymptoms of fever and chills. Patient has never been diagnoes withseasonal allergies but states that her sister has "hay fever". Socialhistory: Patient is unaware of any environmental exposure or irritant.She mentions that she keeps the house "pretty clean". The patientmentions that she used "pot in highchool and after highschool butdefinitely don't anymore". She states she hasn't smoked pot sinceshe was 21. The patient does not exercise however is on her feetmost o0f the time at work. Review system: General- Denies change in weight, fever and chills.Head- denies history of trauma but mentions headaches d/t studyingfor long perios of the time, takes Tylenol to help alleviate the pain.Eyes- patient denies wearing glasses or contacts however notes thevision is sort of blurry when reading and is currently getting worse.Ears- denies hrearing loss, tinnitus, vertigo or discharge. Patientstates her ears are "fine". Nose- Denies any problem with nose priorto this issue, denies stuﬃness, sneezing,states allergies to cats anddust. Mouth- denies bleeding gum, hoarsness, swollen lypmphnodes. Respiratory- denies shortness of breath, cough, history oftuberculosis or bronchitis. Patient has asthma and uses inhaler 2-3times per week. Her last chest xray was in high school.