States that she has some soreness when swallowing but

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states that she has some soreness when swallowing,but otherwise no other associated symptoms. Shestates that her nose “runs all day” and is cleardischarge. She has not attempted any treatment forher nasal symptoms. She states that her eyes areconstantly itchy and she has not attempted any eyespecific treatment. She denies cough and recentillness. She has had no exposures to sickindividuals. She denies changes in her hearing,vision, and taste. She denies fevers, chills, and nightsweats. She has never been diagnosed withseasonal allergies, but does note that her sister has“hay fever”.Social History: She is not aware of anyenvironmental exposures or irritants at her job orhome. She changes her sheets weekly and deniesdust/mildew at her home. She denies use of tobacco,alcohol, and illicit drugs. She does not exercise.Review of Systems: General: Denies changes inweight, fatigue, weakness, fever, chills, and nightDocumentation / Electronic Health Record© Shadow Health2018®HEENT Physical Assessment Assignment | Completed | Shadow Health1 of 311/20/2018, 5:42 PM
Student DocumentationStudent DocumentationModel DocumentationModel DocumentationEars: patient denies any hearing loss, discharge,aching, or ringingNose: patient denies any sinus issues or nosebleedsMouth/Throat: patient denies any mouth or dentalissues. patient denies any swollen lymph nosedRespiratory: patient has astham, but denies anyweezing or generally being short of breath. She usesher inhaler 2-3 times weekly as needed.sweats.• Head: Denies history of trauma or headaches.• Eyes: She does not wear corrective lenses, butnotes that her vision has been worsening over thepast few years. She complains of blurry vision afterreading for extended periods. Denies increasedtearing or itching prior to this past week.• Ears: Denies hearing loss, tinnitus, vertigo,discharge, or earache.• Nose/Sinuses: Denies rhinorrhea prior to thisepisode. Denies stuffiness, sneezing, itching,previous allergy, epistaxis, or sinus pressure.• Mouth/Throat: Denies bleeding gums, hoarseness,swollen lymph nodes, or wounds in mouth. No sorethroat prior to this episode.

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