Student Documentation Model Documentation no wounds visualized Adequate dental

Student documentation model documentation no wounds

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Student Documentation Model Documentation no wounds visualized. Adequate dental hygiene. Uvula midline. Tonsils 1+ and without evidence of inflammation. Posterior pharynx is slightly erythematous with mild cobblestoning. •Neck: No cervical, infraclavicular lymphadenopathy. Thyroid is smooth without nodules or goiter. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation without wheezes, crackles, or cough. Assessment Allergic Rhinitis Allergic Rhinitis Plan Claritin 10mg by mouth daily encourage to increase fluid intake Avoid allergy triggers Come back when symptoms are worsening such as uncontrolled nose bleedin, fever, headaches follow up within 1 month for evaluation Encourage Ms. Jones to continue to monitor symptoms and log her episodes of allergic symptoms with associated factors and bring log to next visit. • Initiate trial of loratadine (Claritin) 10 mg by mouth daily. • Encourage to increase intake of water and other fluids and educate on frequent handwashing. • Educate on avoidance of triggers and known allergens • Educate Ms. Jones on when to seek care including episodes of uncontrollable epistaxis, worsening headache, or fever. • Revisit clinic in 2-4 weeks for follow up and evaluation.
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  • Winter '18
  • Jane Doe

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