HEENT SOA DOCUMENTATION
SUBJECTIVE
Identifying Data & Reliability -Tina Jones, 28 years old African American female. She is the
primary source of this interview. She is alert and oriented, maintains good eye contact
throughout the interview.
Chief Complaint – My throat has been sore... and itchy. And my nose won't stop running. These
symptoms are driving me nuts.
History Of Present Illness
Tina Jones, 28 years old African American female who presented to the clinic with complaints of
sore, itchy throat, itchy eyes, and runny nose. Patient stated it all started a week ago. She does
not know what caused the symptoms, but added that symptoms are worse in the morning, and
rated throat pain 4/10. Patient denies any sinus pain, but added her nose runs all day with clear
discharge, and that her eyes itch constantly all day. Patient has not taken any medication for her
itchy eyes and runny nose. She has used lozenges to treat her sore throat occasionally, which
helped a little.
Medications – Patient confirmed medications from previous visit. Treat asthma with albuterol
inhaler 90mcg/spray.
Lozenges as treatment for sore throat.
Allergies – Allergic to penicillin- patient get rash and hives from penicillin allergies.
Patient is also allergic to dust and cats.
Review of Systems (ROS) – Ms. Jones is an obese 28-year-old African American woman. She
is alert and in no acute distress currently.
General: Denies fatigue, SOB
Head and Neck: No complaints with head. Reports headaches after long hours of studying. Take
Tylenol for pain reliever. Scalp with no masses, normal hair distribution.
Eyes: c/o vision changes, blurry vision
Ear: no complaints.
Nose: denies any pain or changes in smell.
Breast: denies breast lumps/pain.
Respiratory: Reports asthma, wheezing triggers when exposed to cats and dust.
Cardiovascular: Denies chest pain.
Gastrointestinal: Reports changes in appetites, denies abdominal pain.
GU: reports excessive thirst-polydipsia.
Reproductive: reports dysmenorrheal, gets bad cramps during menstrual period; denies STI
symptoms. Pt has never been pregnant, and not sexually active at this time. Last menstruation
was 3 weeks ago.
Musculoskeletal: denies muscle aches/stiffness, numbness, joint pain/swelling.
Neurological: Denies weakness, changes in sensation
Endocrine: Reports excessive thirst, frequent urination, unintentional weight loss of 10 lbs
weight loss in 1 month. Denies sweating.
This study source was downloaded by 100000804717335 from CourseHero.com on 11-21-2025 02:39:03 GMT -06:00
https://www.coursehero.com/file/245891448/Nur-6001-Wk-2-HEENT-SOA-DOCUMENTATION-1docx/
SUBJECTIVE
Identifying Data & Reliability -Tina Jones, 28 years old African American female. She is the
primary source of this interview. She is alert and oriented, maintains good eye contact
throughout the interview.
Chief Complaint – My throat has been sore... and itchy. And my nose won't stop running. These
symptoms are driving me nuts.
History Of Present Illness
Tina Jones, 28 years old African American female who presented to the clinic with complaints of
sore, itchy throat, itchy eyes, and runny nose. Patient stated it all started a week ago. She does
not know what caused the symptoms, but added that symptoms are worse in the morning, and
rated throat pain 4/10. Patient denies any sinus pain, but added her nose runs all day with clear
discharge, and that her eyes itch constantly all day. Patient has not taken any medication for her
itchy eyes and runny nose. She has used lozenges to treat her sore throat occasionally, which
helped a little.
Medications – Patient confirmed medications from previous visit. Treat asthma with albuterol
inhaler 90mcg/spray.
Lozenges as treatment for sore throat.
Allergies – Allergic to penicillin- patient get rash and hives from penicillin allergies.
Patient is also allergic to dust and cats.
Review of Systems (ROS) – Ms. Jones is an obese 28-year-old African American woman. She
is alert and in no acute distress currently.
General: Denies fatigue, SOB
Head and Neck: No complaints with head. Reports headaches after long hours of studying. Take
Tylenol for pain reliever. Scalp with no masses, normal hair distribution.
Eyes: c/o vision changes, blurry vision
Ear: no complaints.
Nose: denies any pain or changes in smell.
Breast: denies breast lumps/pain.
Respiratory: Reports asthma, wheezing triggers when exposed to cats and dust.
Cardiovascular: Denies chest pain.
Gastrointestinal: Reports changes in appetites, denies abdominal pain.
GU: reports excessive thirst-polydipsia.
Reproductive: reports dysmenorrheal, gets bad cramps during menstrual period; denies STI
symptoms. Pt has never been pregnant, and not sexually active at this time. Last menstruation
was 3 weeks ago.
Musculoskeletal: denies muscle aches/stiffness, numbness, joint pain/swelling.
Neurological: Denies weakness, changes in sensation
Endocrine: Reports excessive thirst, frequent urination, unintentional weight loss of 10 lbs
weight loss in 1 month. Denies sweating.
This study source was downloaded by 100000804717335 from CourseHero.com on 11-21-2025 02:39:03 GMT -06:00
https://www.coursehero.com/file/245891448/Nur-6001-Wk-2-HEENT-SOA-DOCUMENTATION-1docx/
