Tina Jones - HEENT EHR Documentation Already Passed

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Documentation / Electronic Health Record  Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective Patiet reports sore and itchy throat and runny ... nose for 1 week Patient itchy eyes for 1 week. Patient states blurred vision when reads, denies wearing glasses or contacts. Patient states throbbing headaches when studying; takes Tylenol to treat headaches; denies any injury Pt denies any change in weight, fatigue, weakness, night sweats, chills, and fever Pt denies any changes in hearing, dizziness, or ear pain Pt states denies nasal congestion; states runny nose with clear discharge pt denies any mouth problems; pt denies any SOB, cough. PMH asthma, treated with Proventil inhaler, used 2-3 times a week; last hospitalization for asthma at 16 yoa 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 or headaches. • Eyes: She does not wear corrective lenses, but notes that her vision has been This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 11:31:32 GMT -05:00 https://www.coursehero.com/file/27874443/Tina-Jones-HEENT-EHR-documentationdocx/ Student Documentation Model Documentation 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. Objective Acne on right side face oropharynx erythematous with mild cobblestoning, post nasal discharge nasal mucosa pale injection noted on sclera visulal acuity: 20/40 right eye, 20/20 left eye General: Ms. Jones is a pleasant, obese 28-yearold 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, This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 11:31:32 GMT -05:00 https://www.coursehero.com/file/27874443/Tina-Jones-HEENT-EHR-documentationdocx/ 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. [Show More]

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