HEENT Tina Jones Transcript and Documentation

Hello, My name is xx. I will be your nurse today.
Greet
Date: 07/19/22 6:58 AM MDT
Tina Jones:
Hey.
Your Avatar:
What brought you here today?
Question
Date: 07/19/22 6:58 AM MDT
Tina Jones:
My throat has been sore and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
Your Avatar:
I am sorry for that. You will be well.
Empathize
Date: 07/19/22 6:59 AM MDT
Tina Jones:
Thanks for understanding.
Your Avatar:
When did the sore throat start?
Question
Date: 07/19/22 6:59 AM MDT
Tina Jones:
Like a week ago, everything started. Sore, itchy throat, runny nose.
Do you have headaches?
Question
Date: 07/21/22 1:50 AM MDT
Tina Jones:
Yeah, I get them a lot when I’m studying.
Your Avatar:
How frequently do the headaches occur?
Question
Date: 07/21/22 1:51 AM MDT
Tina Jones:
Maybe once a week? I usually do a lot of my school work at once, so I’ll study for like, 5 or 6 hours. I usually end up with a headache by the end of the night.
Your Avatar:
How long do your headaches last?
Question
Date: 07/21/22 1:51 AM MDT
Tina Jones:
A few hours, I guess. I usually take some Tylenol and then go to bed to get rid of them.
Your Avatar:
How do the headaches feel like?
Question
Date: 07/21/22 1:52 AM MDT
Tina Jones:
When I get them, the pain is sort of tight and throbbing, I guess.
HEENT Tina Jones Transcript and Documentation On a scale of 1 to 10 how bad are your headaches?
Question
Date: 07/21/22 1:52 AM MDT
Tina Jones:
Not too bad. . . I’d say about 3. Or a 4 if I really push it.
Your Avatar:
What triggers the headache?
Question
Date: 07/21/22 1:53 AM MDT
Tina Jones:
When I get headaches, it’s usually just from reading. I only get them about once a week and it doesn’t really hurt on one side or the other. The pain is mostly behind both eyes.
Your Avatar:
Do you have any vision problem?
Question
Date: 07/21/22 1:56 AM MDT
Tina Jones:
Yeah, maybe so. I’ve noticed my vision getting sort of blurry when I read. It seems like it’s getting a little worse — I notice it more.
Your Avatar:
When did your vision start worsening?
Question
Date: 07/21/22 1:57 AM MDT
Tina Jones:
I’m not sure — Maybe over the last year or so.
Your Avatar:
Are you able to swallow?
Question
Date: 07/22/22 2:01 AM MDT
Tina Jones:
Um, yeah.
Your Avatar:
Is there throat pain while swallowing?
Question
Date: 07/22/22 2:01 AM MDT
Tina Jones:
Yes, it hurts my throat to swallow.
Your Avatar:
What is the rate of throat pain on a scale of 1-10?
Question
Date: 07/22/22 2:02 AM MDT
Tina Jones:
It’s like a 4 out of 10, maybe.
Your Avatar:
Have you taken any treatment at home?
Question
Date: 07/22/22 2:02 AM MDT
Tina Jones:
All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
Have you taken any OTC medication?
Question
Date: 07/22/22 2:02 AM MDT
Tina Jones:
I’ve been using throat drops, like lozenges, for my sore throat. Other than that, I just have my inhaler.
Your Avatar:
Do you have eye pain?
Question
Date: 07/22/22 2:03 AM MDT
Tina Jones:
No, my eyes don’t hurt. They’re just itchy.
Your Avatar:
Do you use glasses or contacts?
Question
Date: 07/22/22 2:03 AM MDT
Tina Jones:
No, I’ve never had glasses or contacts.
Your Avatar:
Does the OTC medication improve the pain?
Does the OTC medication help?
What other medical problem do you have?
Question
Date: 07/22/22 2:05 AM MDT
Tina Jones:
Um, the only things I know I’m diagnosed with are diabetes. And asthma.
Your Avatar:
When were you diagnosed with diabetes?
Question
Date: 07/22/22 2:05 AM MDT
Tina Jones:
I was diagnosed when I was 24.
Your Avatar:
Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported
Exam Action
Date: 07/22/22 2:06 AM MDT
Your Avatar:
Palpated frontal sinuses: No tenderness reported
Exam Action
Date: 07/22/22 2:06 AM MDT
Your Avatar:
Palpated maxillary sinuses: No tenderness reported
Exam Action
Date: 07/22/22 2:07 AM MDT
Your Avatar:
Where is the location of headache?
Question
Date: 07/22/22 2:07 AM MDT
Tina Jones:
It’s kind of behind my forehead.
Your Avatar:
Do you take anything to treat your headaches?
Question
Date: 07/22/22 2:09 AM MDT
Tina Jones:
Yeah. Usually I’ll take a Tylenol and go to bed, and that’ll get rid of it.
Your Avatar:
What triggers your headaches?
Question
Date: 07/22/22 2:09 AM MDT
Tina Jones:
When I get headaches, it’s usually just from reading. I only get them about once a week and it doesn’t really hurt on one side or the other. The pain is mostly behind both eyes.
Your Avatar:
When did your vision begin worsening?
Question
Date: 07/22/22 2:09 AM MDT
Tina Jones:
I’m not sure — Maybe over the last year or so.
Your Avatar:
What makes your blurry vision go away?
Question
Date: 07/22/22 2:10 AM MDT
Tina Jones:
If I stop reading and rest my eyes a bit, then it clears up.
Your Avatar:
When was your last vision exam?
Question
Date: 07/22/22 2:10 AM MDT
Tina Jones:
I

must’ve been… maybe ten the last time the school nurse checked my vision. You know how the school nurses do those little checks every year.
Your Avatar:
Do you have any allergies?
Question
Date: 07/22/22 2:10 AM MDT
Tina Jones:
Yeah. I’m allergic to cats. And dust, too.
Your Avatar:
What triggers the eye symptoms?
Question
Date: 07/22/22 2:12 AM MDT
Tina Jones:
It’s a little worse in the morning, but that’s really the only pattern I’ve noticed.
Your Avatar:
Are you taking medication for the itchy eyes?
Question
Date: 07/22/22 2:15 AM MDT
Tina Jones:
No, I haven’t done anything to try to make my eyes less itchy.
Your Avatar:
Do you have general nose problems?
Question
Date: 07/22/22 2:15 AM MDT
Tina Jones:
Yes, my nose won’t stop running!
Have you had nosebleeds?
Question
Date: 07/22/22 2:18 AM MDT
Tina Jones:
No.
Do you have frequent sinus congestion?
Question
Date: 07/22/22 2:18 AM MDT
Tina Jones:
No, I’m not stuffed up — my nose has been running nonstop!
Do your allergies trigger your runny nose?
Question
Date: 07/22/22 2:19 AM MDT
Tina Jones:
Well, no. I mean, I never had allergies to pollen or anything outdoors like that. But my nose is acting just like my sister’s right now, and she’s always had hay fever. I’m starting to think that this is allergies.
Your Avatar:
How have you been treating your runny nose?
Question
Date: 07/22/22 2:20 AM MDT
Tina Jones:
I haven’t taken anything. Most of the stuff you get over-the-counter dries me out too much.
Do you take alcohol?

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HEENT Tina Jones Transcript and Documentation Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes
Student Documentation Model Documentation
Subjective

Ms. Jones is a pleasant 28-year-old African American female presenting to the clinic due to a sore/itchy throat and runny nose. The symptoms began one week ago. She reports having used over-the-counter throat drops for her sore throat and denies treating runny nose at home. She reports it hurts to swallow and rates her throat pain at 3-4/10. Throat pain is worse in the morning. She also has headaches and blurry vision, especially while reading. She denies eye pain and does not use contacts or glasses. The use of over-the-counter medication improves her headache and vision.

NRS-434VN Health Assessment Full Course GCU

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 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 have “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 the 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 a 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 the 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, with her last hospitalization at age 16 for asthma, and her last chest X-ray was at age 16. Her current inhaler use has been her baseline of 2-3 times per week.

Objective

Ms. Jones is pleasant. She is alert and oriented. She is able to voice her needs and wants. She answers questions appropriately. She is well-groomed and dressed appropriately. She does not appear in any distress at the time of assessment. She has allergic shiners and red, chapped skin around her nares. She has clear postnasal drainage. Moderately erythema. Tonsils are 1+.

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 the interview and examination.
Head: The head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution.
Eyes: Bilateral eyes with…