HEENT Examination – Tina Jones (Shadow Health)
Patient: Tina Jones
Age: 28 years (approx.)
Date: ____________________
Examiner: Sherry Kostman-Cater, PsyD, CCM
Encounter Type: Focused HEENT Exam
S – Subjective
Chief Complaint (CC): "My throat’s been sore and itchy, and my nose just keeps
running."
History of Present Illness (HPI): Tina Jones is a 28-year-old female presenting with a
oneweek history of sore, itchy throat, itchy eyes, and persistent clear nasal drainage.
Symptoms began spontaneously and have remained constant. She describes her
throat as “scratchy,” denies pain with swallowing, and reports watery, itchy eyes. No
fever, chills, or body aches noted. She denies cough, ear pain, or shortness of breath.
Over-the-counter antihistamines (loratadine) provided mild relief. She reports spending
more time outdoors recently and symptoms are worse during the day. No known sick
contacts.
Associated Symptoms:
•Positive: nasal congestion, sneezing, itchy throat, itchy/watery eyes
•Negative: fever, fatigue, sinus pain, cough, ear pain, dizziness
Past Medical History: Seasonal allergic rhinitis diagnosed previously; no history of
sinusitis, otitis media, or strep throat.
Medications: Loratadine (OTC) as needed for allergy symptoms. No other medications.
Allergies: Environmental—pollen, dust (causes sneezing and itchy eyes). No known
drug or food allergies.
Family History: Mother and sister with seasonal allergies. No family history of asthma
or chronic sinusitis.
Social/Environmental History: Non-smoker, no secondhand smoke exposure. Works in
an office. Has a cat at home. Uses central air conditioning; windows occasionally open
during spring.
Review of Systems (Targeted HEENT):
Head: No headaches or dizziness.
Eyes: Itching, redness, watery discharge. No vision changes.
Ears: No pain, ringing, or hearing loss.
Nose: Clear nasal discharge, congestion, sneezing. No epistaxis.
Throat/Mouth: Sore, itchy throat. No odynophagia, ulcers, or hoarseness.
Neck: No pain, lumps, or stiffness.
1.
Patient: Tina Jones
Age: 28 years (approx.)
Date: ____________________
Examiner: Sherry Kostman-Cater, PsyD, CCM
Encounter Type: Focused HEENT Exam
S – Subjective
Chief Complaint (CC): "My throat’s been sore and itchy, and my nose just keeps
running."
History of Present Illness (HPI): Tina Jones is a 28-year-old female presenting with a
oneweek history of sore, itchy throat, itchy eyes, and persistent clear nasal drainage.
Symptoms began spontaneously and have remained constant. She describes her
throat as “scratchy,” denies pain with swallowing, and reports watery, itchy eyes. No
fever, chills, or body aches noted. She denies cough, ear pain, or shortness of breath.
Over-the-counter antihistamines (loratadine) provided mild relief. She reports spending
more time outdoors recently and symptoms are worse during the day. No known sick
contacts.
Associated Symptoms:
•Positive: nasal congestion, sneezing, itchy throat, itchy/watery eyes
•Negative: fever, fatigue, sinus pain, cough, ear pain, dizziness
Past Medical History: Seasonal allergic rhinitis diagnosed previously; no history of
sinusitis, otitis media, or strep throat.
Medications: Loratadine (OTC) as needed for allergy symptoms. No other medications.
Allergies: Environmental—pollen, dust (causes sneezing and itchy eyes). No known
drug or food allergies.
Family History: Mother and sister with seasonal allergies. No family history of asthma
or chronic sinusitis.
Social/Environmental History: Non-smoker, no secondhand smoke exposure. Works in
an office. Has a cat at home. Uses central air conditioning; windows occasionally open
during spring.
Review of Systems (Targeted HEENT):
Head: No headaches or dizziness.
Eyes: Itching, redness, watery discharge. No vision changes.
Ears: No pain, ringing, or hearing loss.
Nose: Clear nasal discharge, congestion, sneezing. No epistaxis.
Throat/Mouth: Sore, itchy throat. No odynophagia, ulcers, or hoarseness.
Neck: No pain, lumps, or stiffness.
1.
