NR 509 HEENT Documentation Shadow Health

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HEENT Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment Your Results Overview Transcript Subjective Data Collec ... tion Objective Data Collection Education & Empathy Documentation Lifespan Review Questions Self-Reflection Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective Tina Jones is a 28 year old African American female. She came to see me with complaints of a sore and itchy throat, a runny nose, and itchy eyes for about a week. They started with no appranet cause and have been constant. There are no obvious causes. She rates the pain in her throat as mild to moderate. Her throat hurts when she swallows. Her nose runs constantly, and it is clear discharge. She has taken lozenges for her throat, as well as increased water intake, but she has not taken anything else for her eyes or her runny nose. Patient denies a cough or any recent illnesses. She claims that she has not been exposed to anything that could cause her symtpoms. She denies any changes in any other body systems. She claims that she has never been diagnosed with environmental allergies, just dust and cats. The patient does not smoke or do drugs. RoS: General: patient denies being sick recently, denies running a fever, normal energy level Head: patient denies trauma, but does have regular headaches Eyes: patient claims she has blurry vission after reading, but denies any other eye trauma. She does not wear corrective lenses. 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 Documentation / Electronic Health Record © Shadow Health 2018 ® HEENT Physical Assessment Assignment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/4154051 1 of 3 11/20/2018, 5:42 PM This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 11:34:06 GMT -05:00 https://www.coursehero.com/file/35687654/NR-509-HEENT-Documentation-Shadowpdf/ Student Documentation Model Documentation Ears: patient denies any hearing loss, discharge, aching, or ringing Nose: patient denies any sinus issues or nosebleeds Mouth/Throat: patient denies any mouth or dental issues. patient denies any swollen lymph nosed Respiratory: patient has astham, but denies any weezing or generally being short of breath. She uses her inhaler 2-3 times weekly as needed. sweats. • Head: Denies history of trauma or headaches. • 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. Objective Tina is agreeable and well-maintained. She is obese, but in no apparent distress. She is alert and answers questions appropriately. Head: symmetric and normocephalic. No trauma. Normal hair. No masses on scalp. Eyes: Bilateral. No lesions. Clear and injected conjunctiva. Pupils equal and reactive to light. Left fundoscopic exam shows sharp disk margins. Right eye vision: 20/40, left eye vision: 20/20 Ears: equal shape, no inflammation, tympanic membranes pearly gray, psitive light reflex, and intact. Rhine, Weber, and Whisper tests normal. Nose: Boggy and pale mucosa, no pain with palpaption of sinuses Mouth/Throat: Buccal mucosa was moist, no wounds, good dental hygiene, no evidence of tonsil infalmmation, tonsil 1+. Postererior phrynx was a little erythematous and had mild cobblestoning. Neck: no cervical lymphadenopathy. No nodules on thyroid. Found acanthosis nigricans around the whole neck. Carotid is 2+ with no thrills. Jaw did not click. Carotid auscultation with no brui. Respiratory: Symmetrical chest respirations. Lung sounds were clear. No cough. 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. Assessment Allergic Rhinitis Allergic Rhinitis HEENT Physical Assessment Assignment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/4154051 2 of 3 11/20/2018, 5:42 PM This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 11:34:06 GMT -05:00 https://www.coursehero.com/file/35687654/NR-509-HEENT-Documentation-Shadowpdf/ Comments Olivia Mgbeokwere (09 Nov 2018, 10:07 PM CST): Dear Student, Nice work! You did a good job with this case study. But you are missing some pertinent information.. HPI/Social Hx/ROS/ differentials/etc. Of course, there is always room for improvement. Please take time to review your results and the feedback provided by Shadow Health. Compare your performance with the model note. It is important to understand where you may have missed opportunities to be more effective or enhance your skills. On the physical exam, you should have noted that the posterior pharynx was slightly erythematous with mild cobblestoning. This was a hallmark clue to the the presence of chronic postnasal drip. Cobblestoning is a widely used adjective referring to an appearance, morphology or pattern characterized by multiple, similarly-sized rounded densities that project from a single linear surface when the image is 2-D or that rise above a flattened plane when viewed in 3-D, a pattern which has been likened to pre-internal combustion engine roads paved with ‘cobbled’ stones. Therefore, the primary diagnosis of allergic rhinitis was correct. With a myriad of treatment options available on the market for AR, how did you decide to select specific medications? What treatment g [Show More]

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