HEENT Tina Jones Shadow Health Transcript
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.
Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
Subjective
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HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of a sore, itchy throat, itchy eyes, and a runny nose for the last week. She states that these symptoms started spontaneously and have been constant. Her throat pain rates 4/10, and throat itchiness rates 5/10. Throat lozenges have provided some relief. She experiences soreness when swallowing but no other associated symptoms. Her nose has clear discharge and runs all day, and her eyes are constantly itchy. She denies cough and recent illness and has had no exposure to sick individuals. She denies changes in hearing, vision, and taste. She has no history of seasonal allergies but mentions her sister has “hay fever.”
Social History: No environmental exposures or irritants noted at her job or home. She changes her sheets weekly and denies dust/mildew at home. Denies use of tobacco, alcohol, and illicit drugs. No regular exercise.
Review of Systems:
General: No changes in weight, fatigue, weakness, fever, chills, or night sweats.
Head: Reports headaches while studying.
Eyes: Vision worsening over the past few years, blurry vision after reading for extended periods. No increased tearing or itching prior to this past week.
Ears: No hearing loss, tinnitus, vertigo, discharge, or earache.
Nose/Sinuses: No rhinorrhea before this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure.
Mouth/Throat: No bleeding gums, hoarseness, swollen lymph nodes, or wounds in the mouth. No sore throat before this episode.
Respiratory: No shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. History of asthma, last hospitalization at age 16 for asthma, last chest XR at age 16. Current inhaler use at baseline of 2-3 times per week.
Objective
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General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. Alert and oriented.
Head: Normocephalic and atraumatic. Scalp with no masses, normal hair distribution.
Eyes: Bilateral eyes with equal hair distribution, no lesions, ptosis, or edema. Clear and injected conjunctiva. 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: Equal ear shape 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: Midline septum, boggy and pale nasal mucosa bilaterally. No pain with palpation of frontal or maxillary sinuses.
Mouth/Throat: Moist buccal mucosa, no wounds visualized. Adequate dental hygiene. Midline uvula. Tonsils 1+ without inflammation. Slightly erythematous posterior pharynx with mild cobblestoning.
Neck: No cervical, infraclavicular lymphadenopathy. Smooth thyroid without nodules or goiter. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Full range of motion in the jaw. Bilateral carotid artery auscultation without bruit.
Respiratory: Symmetrical chest with clear lung sounds to auscultation. No wheezes, crackles, or cough.
Assessment
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Allergic Rhinitis
Plan
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Encourage Ms. Jones to continue to monitor symptoms and log her episodes of allergic symptoms with associated factors for the next visit.
Initiate a trial of loratadine (Claritin) 10 mg by mouth daily.
Encourage increased intake of water and other fluids and educate on frequent handwashing.
Educate on avoiding triggers and known allergens.
Educate Ms. Jones on when to seek care for uncontrollable epistaxis, worsening headache, or fever.
Revisit the clinic in 2-4 weeks for follow-up and evaluation.
