Summary HEENT Physical Assessment Assignment

HEENT Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment Your Results Subjective Data Collection: 27 of 28 (96.4%) 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 the patient's case. Chief Complaint Established chief complaint Reports sore throat Reports itchy throat Reports itchy eyes Reports runny nose History of Present Illness Asked about onset of symptoms Reports sore throat began "about a week ago" Reports runny nose began "about a week ago" Reports itchy eyes began "about a week ago" Asked about aggravating factors for throat s©ymSphtoamdosw Health® 2018 Reports throat pain is constant Reports throat pain is worse in the morning Reports some soreness with swallowing Asked severity of throat discomfort Describes sore throat as mild to moderate Asked about frequency and duration of runny nose Reports nose is runny "pretty much all day" Asked about character of 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 purulent discharge 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 exposure to allergens Reports no exposure to cats Reports no exposure to mold or mildew Reports no exposure to dust Reports no known exposure to irritants in work environment Reports changing bedding "once a week" Asked about perceived cause of symptoms Describes symptoms as similar to allergies Reports that the symptoms don't seem like a common cold Describes similarity to her sister's hay fever symptoms Reports no history of cigarette smoking Reports no recent exposure to secondhand smoke Medical History Confirmed use of medications Confirmed medications from previous visit (no new medications) Followed up about inhaler use Uses an inhaler to treat asthma symptoms Inhaler is Proventil Last use of inhaler was last week Reports typical inhaler use is 2 - 3 times a week Reports using 2 - 3 puffs of inhaler when used Prescribed dosage is 2 puffs Followed up about medications and relieving factors for nose and eye symptoms Reports no treatment for itchy eyes Reports no treatment for nasal symptoms Reports no antihistamine Reports no decongestant Followed up about medications and relieving factors for throat symptoms Reports lozenges as treatment Reports lozenges reduce symptoms Reports ingesting lozenges every few hours Reports drinking water reduces symptoms