HEENT _Provider_Documentation_ Completed _ Shadow Health.pdf - HEENT | Completed | Shadow Health HEENT Results | Turned In Advanced Health Assessment

HEENT _Provider_Documentation_ Completed _ Shadow...

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8/16/2020 HEENT | Completed | Shadow Health 1/2 HEENT Results | Turned In Advanced Health Assessment - July 2020, NURP 500/530 Return to Assignment (/assignments/356673/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Subjective Mrs Jones is a 28 year old afterican american women who is presented to the clinic with compliants of sore, itchy throat and runny noes for the past week. She states the throat pain is bad and rates it a 4/10. She states that these symptoms started spontaneously and have been constant and nature. She does not know any specific aggravating symptoms, but states that her throat pain seems to be worse in the morning. She states that she has treated her throat pain with occasional throat lozenges which has "help a little". The patient mentions that it hurts to swallow and that her eyes are itchy. She denies taking anything to stop her nasal irritation and itchy eyes. She states that her nose "runs all day" and is clear in discharge. she has not attempted any treatment for her nasal symptoms. Patient denies exposure to sick individuals, denies symptoms of fever and chills. Patient has never been diagnoes with seasonal allergies but states that her sister has "hay fever". Social history: Patient is unaware of any environmental exposure or irritant. She mentions that she keeps the house "pretty clean". The patient mentions that she used "pot in highchool and after highschool but definitely don't anymore". She states she hasn't smoked pot since she was 21. The patient does not exercise however is on her feet most 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 studying for long perios of the time, takes Tylenol to help alleviate the pain. Eyes- patient denies wearing glasses or contacts however notes the vision is sort of blurry when reading and is currently getting worse. Ears- denies hrearing loss, tinnitus, vertigo or discharge. Patient states her ears are "fine". Nose- Denies any problem with nose prior to this issue, denies stuffiness, sneezing,states allergies to cats and dust. Mouth- denies bleeding gum, hoarsness, swollen lypmph nodes. Respiratory- denies shortness of breath, cough, history of tuberculosis or bronchitis. Patient has asthma and uses inhaler 2-3 times per week. Her last chest xray was in high school.
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