Tina Jones HEENT Documentation/Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
Subjective
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Patient Information:
Ms. Jones is a friendly 28-year-old African American woman who came to the clinic with complaints of a sore, itchy throat, itchy eyes, and a runny nose that have bothered her for the past week. She mentioned that these symptoms started suddenly and have remained constant. While there are no specific triggers, she noted that her throat feels worse in the morning.
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She rates her throat pain as 4 out of 10 and her throat itchiness as 5 out of 10. She has used throat lozenges occasionally, which provided some relief. She does experience discomfort while swallowing but no other related symptoms. Her nose has been running all day with clear discharge, and she hasn’t tried any treatment for it. Her eyes are persistently itchy, and she hasn’t attempted any specific eye treatments. She denies having a cough or recent illnesses. She hasn’t been around sick individuals either. There have been no changes in her hearing, vision, or taste. She hasn’t had fevers, chills, or night sweats. While she hasn’t been diagnosed with seasonal allergies, she mentioned that her sister has hay fever.
Social History:
Ms. Jones is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies having dust or mildew in her home. She doesn’t use tobacco, alcohol, or illicit drugs and doesn’t engage in exercise.
Review of Systems:
– General: No changes in weight, fatigue, weakness, fever, chills, or night sweats.
– Head: No history of head trauma. Reports headaches during studying.
– Eyes: Doesn’t use corrective lenses but noted worsening vision over the past few years, especially after extended reading. Denies increased tearing or itching before this past week.
– Ears: No hearing loss, tinnitus, vertigo, discharge, or earache.
– Nose/Sinuses: No runny nose before this episode. Denies stuffiness, sneezing, itching, previous allergies, nosebleeds, or sinus pressure.
– Mouth/Throat: No bleeding gums, hoarseness, swollen lymph nodes, or mouth wounds. No sore throat before this episode.
– Respiratory: Denies shortness of breath, wheezing, cough, sputum, coughing up blood, pneumonia, bronchitis, emphysema, or tuberculosis. She has a history of asthma, last hospitalized at age 16 for asthma, and her last chest X-ray was at age 16. Her current inhaler use has been her usual 2-3 times per week.
Objective
General:
Ms. Jones is a pleasant, overweight 28-year-old African American woman in good overall condition. She is alert and aware, maintaining eye contact throughout the interview and examination.
Head:
Her head is of normal size and free from injury. There are no unusual masses, and her hair distribution is normal.
Eyes:
Both eyes are equal in terms of hair distribution, with no lesions, ptosis, or swelling. The conjunctiva is clear and slightly red. Eye movements are normal in both eyes, and pupils are equal in size, round, and react to light. Convergence is normal. In the left eye, the fundoscopic exam reveals well-defined disc margins and no hemorrhages. The right eye shows slight retinopathic changes. Vision in the left eye is 20/20, while the right eye is 20/40.
Ears:
Both ears have the same shape. There is no inflammation in the external ear canals. The eardrums are a pearly gray color and intact, with a positive light reflection in both ears. Rinne, Weber, and Whisper tests are normal in both ears.
Nose:
The nasal septum is in the middle, and the nasal mucosa is swollen and pale in both nostrils. There is no pain when touching the frontal or maxillary sinuses.
Mouth/Throat:
Her buccal mucosa is moist, with no visible wounds. Her dental hygiene is adequate. The uvula is in the middle, and her tonsils are graded as 1+ without signs of inflammation. The back of the throat is slightly red with mild cobblestoning.
Neck:
There are no swollen lymph nodes in the neck or below the collarbone. The thyroid is smooth without nodules or enlargement. A skin condition called acanthosis nigricans is present. Carotid pulses are strong (2+) without any unusual vibrations (thrills). There are no clicking sounds in the jaw, and she has a full range of motion. Both carotid arteries are listened to without any abnormal sounds.
Respiratory:
Her chest appears symmetrical during breathing. Lung sounds are clear when listening, with no wheezing, crackling, or cough.
Assessment
Diagnosis:
Allergic Rhinitis
Plan
Treatment Plan:
– Encourage Ms. Jones to keep track of her symptoms and note any factors that might be linked to her allergies. She should bring this record to her next appointment.
– Start a trial of loratadine (Claritin) at a dose of 10 mg by mouth daily.
– Advise her to increase her fluid intake and emphasize the importance of frequent handwashing.
– Educate Ms. Jones about avoiding triggers and known allergens.
– Inform Ms. Jones about when to seek medical care, particularly if she experiences uncontrollable nosebleeds, worsening headaches, or fever.
– Schedule a follow-up clinic appointment in 2-4 weeks for further evaluation and monitoring.
Document: Provider Notes
| Student Documentation | Model Documentation |
|---|---|
Subjectivexx |
HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of sore, itchy throat, itchy eyes, and runny nose for the last week. She states that these symptoms started spontaneously and have been constant in nature. She does not note any specific aggravating symptoms, but states that her throat pain seems to be worse in the morning. She rates her throat pain as 4/10 and her throat itchiness as 5/10. She has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that she has some soreness when swallowing, but otherwise no other associated symptoms. She states that her nose “runs all day” and is clear discharge. She has not attempted any treatment for her nasal symptoms. She states that her eyes are constantly itchy and she has not attempted any eye specific treatment. She denies cough and recent illness. She has had no exposures to sick individuals. She denies changes in her hearing, vision, and taste. She denies fevers, chills, and night sweats. She has never been diagnosed with seasonal allergies, but does note that her sister has “hay fever”. Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history of trauma. Reports headaches while studying. • Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching prior to this past week. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea prior to this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth. No sore throat prior to this episode. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week. |
Objectivexx |
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Rinne, Weber, and Whisper tests normal bilaterally. • Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain with palpation of frontal or maxillary sinuses. • Mouth/Throat: Moist buccal mucosa, 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. |
Assessmentxx |
Allergic Rhinitis |
Planxxx |
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. Dont wait until the last minute.Provide your requirements and let our native nursing writers deliver your assignments ASAP. |