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Subjective DataHEENTMs. Jones states that she gets headaches when reading or studying. These headaches feel tight and throbbing behind her eyes. The headaches last for a couple of hours. She takes Tylenol to help with the headaches. There is no family history of headaches. She denies any head trauma. Patient states that her vision gets blurry when reading or studying. She states that her eyes do nothurt when her vision gets blurry. Her eyes get red and itchy when she is around cats. She also sneezes and experiences rhinitis and congestion around cats. She has not had an eye exam since childhood. She does not wear glasses or contacts. She states that she has no problems with her mouth. She states that her nose is fine, denies nasal discharge. She states that her hearing is fine.There is no family history of hearing problems. She denies head and neck trauma, ringing in the ears, ear pain, discharge, and loss of balance. She does not have a history of sinus problems, frequent colds or infections. She denies difficulty swallowing and changes to her voice. She denies any dental issues and has not gone to the dentist since she was a kid. She has not had anychanges in her taste. 5
TINA JONES HEALTH HISTORY NARRATIVECardiovascularMs. Jones denies cough, chest pain, palpations, dyspnea on exertion, dyspnea, peripheral edema, varicosities, she states other than her right foot she does not have pain in lower extremities. She denies a history of cardiac problems, stroke, and heart attack. RespiratoryPatient states that she has not had a full-blown asthma attack in years, but had to use her inhaler a few days ago when she was visiting her cousin. Cats are what usually triggers problems with her asthma. She states that she is allergic to cats. She was able to breathe normally after a few puffs of her inhaler. She uses a regular Proventil inhaler since she was a kid. Her younger sister also has asthma. She denies: cough, shortness of breath, chest pain, and congestion. She admits that she gets congested around cats. Her sister rarely has issues with her asthmas. She denies smoking, drug use, and she denies the use of tobacco. She is only around second hand smoke when she goes out with friends. She has been hospitalized as a child and in high school for problems with her asthma. She denies a history of TB, chest pain, difficulty breathing, and cough. AbdominalMs. Jones denies digestive problems. She states that she has recently lost ten pounds without trying over the past month. She denies flank pain, dysuria, and urgency. She denies UTI’s. She also states that she is really thirsty and has been drinking a lot of water. She denies, reflux, problems swallowing, nausea, vomiting, constipation, changes in bowel habits, abdominalpain, and blood in her urine. Polyphagia, polydipsia, polyuria, and nocturia have been occurring during the past month. She denies vaginal discharge and itching. She does not have a history of sexually transmitted diseases. She has never been pregnant. Her period are irregular.