TINA JONES SUBJECTIVE HEENT _ Completed _ Shadow Health.

Your Results Lab Pass (/assignment_attempts//lab_pass.p Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of t patient's case. Established chief complaint Reports sore throat Reports itchy throat Reports itchy eyes Reports runny nose Asked about onset of symptoms Reports sore throat began 1 week ago Reports runny nose began 1 week ago Reports itchy eyes began 1 week ago Asked about aggravating factors for throat symptoms Reports throat pain is constant Reports throat pain is worse in the morning Reports some soreness with swallowing Asked severity of throat discomfort Reports sore throat discomfort as mild to moderate Asked about frequency and duration of runny nose Reports runny nose is constant Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. This study source was downloaded by from CourseH on :02:02 GMT -06:00 4/4/2020 HEENT | Completed | Shadow Health Home Medications Social Determinants of Health Followed up on nasal symptoms Denies itchy nose Denies sinus pain Denies sinus pressure Denies sneezing Followed up about character of nasal discharge Reports clear discharge Reports thin discharge Denies pus Asked about eye symptoms Reports eye itching is constant Reports eye redness Asked related respiratory symptoms Reports breathing isn't affected Denies cough Denies chest tightness Asked about related asthma symptoms Denies recent wheezing Denies increase in recent asthma symptoms Asked about perceived cause of symptoms Reports symptoms are similar to allergies Reports symptoms don't seem like a common cold Reports similarity to her sister's hay fever symptoms Asked about relieving factors for nose and eye symptoms Denies treatment for itchy eyes Denies treatment for nasal symptoms Denies taking antihistamine Denies taking decongestant Asked about relieving factors for throat symptoms Reports lozenges as treatment Reports lozenges reduce symptoms Reports ingesting lozenges every few hours Reports drinking water reduces symptoms Confirmed home medications Reports no new medications Followed up about inhaler use Reports using an inhaler to treat asthma symptoms Reports inhaler is albuterol (Proventil) Reports last use of inhaler was 1 week ago Reports typical inhaler use is 2 - 3 times a week Reports using 2 - 3 puffs of inhaler when used Reports prescribed dosage is 2 puffs Asked about environmental exposure to allergens Denies exposure to cats Denies exposure to mold or mildew Denies exposure to dust Denies exposure to irritants in work environment Reports changing bedding once a week This study source was downloaded by from CourseH on :02:02 GMT -06:00 4/4/2020 HEENT | Completed | Shadow Health Relevant Medical History Review of Systems Denies history of cigarette smoking Denies recent exposure to secondhand smoke Asked about healthcare access Reports last vision exam was in childhood Reports last hearing test was in childhood Reports dental visit within the last 2 years Reports regular dental visits in childhood Denies vision insurance Denies dental insurance Confirmed allergies Reports known allergy to cats Reports known allergy to dust Denies seasonal allergies Asked about constitutional health Denies recent or frequent illnesses Denies chills Denies fever Reports low energy level Denies nausea or vomiting Asked about review of systems for head Reports occasional headaches Denies current headache Denies history of head injury Denies lightheadedness Followed up on headaches Reports headaches occur once a week Reports headaches last a few hours Reports headaches feel tight and throbbing Reports headache location is behind her forehead Reports headache pain as a 3 or 4 Reports treating headaches with acetaminophen (Tylenol) Reports reading and studying seem to cause headaches Asked about review of systems for eyes Reports occasional blurry vision Reports worsening vision Denies eye pain Denies dry eyes Denies corrective lenses Followed up on vision problems Reports blurry vision as fuzzy letters Reports blurry vision occurs when reading for long periods Reports blurry vision occurs after 2+ hours of reading Reports that blurry vision and headaches often coincide Asked about review of systems for ears Denies general ear problems Denies change in hearing This study source was downloaded by from CourseH on :02:02 GMT -06:00 Denies ear pain 4/4/2020 HEENT | Completed | Shadow Health Relevant Family History Denies ear discharge Asked about review of systems for nose Denies change in sense of smell Denies nasal or sinus surgeries Denies nosebleeds Asked about review of systems for mouth and jaw Denies general mouth problems Denies change in sense of taste Denies dry mouth Denies history of oral surgery Denies mouth pain Denies mouth sores Denies gum problems Denies tongue problems Denies jaw problems Asked about review of systems for dentation Denies current dental problems Reports a few cavities in childhood Asked about review of systems for neck, throat and glands Denies history of recurrent strep throat Denies lymph node problems Denies history of general throat problems Denies voice changes Denies history of tonsil problems Denies general neck pain Asked about relevant family history Reports sister with hay fever Denies family history of vision problems Denies family history of sinus problems Denies family history of ear or hearing problems Denies family history of mouth, throat, or gland problems Denies family history of headache or migraine