Summary Tina Jones Health Assessment shadow Health Nursing-HEENT HPI 2020

ANHPI: 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 the symptoms started spontaneously and have been constant in nature She does not note any specific aggravating symptoms, but state that her throat pain seems to be worse in the morning. She rates throat pain as 4/10 and her throat itchiness as 5/10. She has tre her throat pain with occasional throat lozenges which has “helpe little”. She states that she has some soreness when swallowing, otherwise no other associated symptoms. She states that her no “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. Sh 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 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 worsening over the past few years. She complai of blurry vision after reading for extended periods. Denies increa tearing or itching prior to this past week. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earac • 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 lym 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 wa age 16 for asthma, last chest XR was age 16. Her current inhaler has been her baseline of 2-3 times per week.