HEENT TINA JONES TRANSCRIPT AND DOCUMENTATION

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HEENT TINA JONES TRANSCRIPT AND DOCUMENTATION

HEENT Tina Jones Transcript and Documentation
HEENT Tina Jones Transcript and Documentation
Transcript

Started: Jul 19, 2022 | Total Time: 62 min

All Lines (147)Interview Questions (64)Statements (1)Exam Actions (82)

Hello, My name is xx. I will be yours nurse today.

Greet
07/19/22 6:58 AM MDT

Hey.

What brought you here today?

Question
07/19/22 6:58 AM MDT

My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.

I am sorry for that. You will be well.

Empathize
07/19/22 6:59 AM MDT

Thanks for understanding.

When did the sore throat start? HEENT Tina Jones Transcript and Documentation

Question
07/19/22 6:59 AM MDT

Like a week ago, everything started. Sore, itchy throat, runny nose.

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Do you have headaches?

Question
07/21/22 1:50 AM MDT

Yeah, I get them a lot when I’m studying.

How frequently do the headaches occur?

Question
07/21/22 1:51 AM MDT

Maybe once a week? I usually do a lot of my school work at once, so I’ll study for like, 5 or 6 hours. I usually end up with a headache by the end of the night.

How long do your headaches last?

Question
07/21/22 1:51 AM MDT

A few hours, I guess. I usually take some Tylenol and then go to bed to get rid of them.

How do the headaches feel like?

Question
07/21/22 1:52 AM MDT

When I get them, the pain is sort of… tight and throbbing, I guess.

HEENT Tina Jones Transcript and Documentation On a scale of 1 to 10 how bad are your headaches?

Question
07/21/22 1:52 AM MDT

Not too bad. . . I’d say about 3. Or a 4 if I really push it.

What triggers the headache?

Question
07/21/22 1:53 AM MDT

When I get headaches, it’s usually just from reading. I only get them about once a week and it doesn’t really hurt on one side or the other. The pain is mostly behind both eyes.

Do you have any vision problem?

Question
07/21/22 1:56 AM MDT

Yeah, maybe so. I’ve noticed my vision getting sort of blurry when I read. It seems like it’s getting a little worse — I notice it more.

When did your vision start worsening?

Question
07/21/22 1:57 AM MDT

I’m not sure — Maybe over the last year or so.

Are you able to swallow?

Question
07/22/22 2:01 AM MDT

Um, yeah.

Is there throat pain while swallowing?

Question
07/22/22 2:01 AM MDT

Yes, it hurts my throat to swallow.

What is the rate of throat pain on a scale of 1-10?

Question
07/22/22 2:02 AM MDT

It’s like a 4 out of 10, maybe.

Have you taken any treatment at home? (Clarified to Have you tried treatments at home?.)

Question
07/22/22 2:02 AM MDT

All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps. (Clarified to if I have tried treatments at home.)

Have you taken any OTC medication?

Question
07/22/22 2:02 AM MDT

I’ve been using throat drops, like lozenges, for my sore throat. Other than that, I just have my inhaler.

Do you have eye pain?

Question
07/22/22 2:03 AM MDT

No, my eyes don’t hurt. They’re just itchy.

Do you use glasses or contacts?

Question
07/22/22 2:03 AM MDT

No, I’ve never had glasses or contacts.

Does the OTC medication improve the pain? (No matching questions found.)

Question
07/22/22 2:04 AM MDT

Does the OTC medication help? (No matching questions found.)

Question
07/22/22 2:04 AM MDT

What other medical problem do you have? HEENT Tina Jones Transcript and Documentation

Question
07/22/22 2:05 AM MDT

Um, the only things I know I’m diagnosed with are diabetes. And asthma.

When were you diagnosed with diabetes?

Question
07/22/22 2:05 AM MDT

I was diagnosed when I was 24.

 Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported

Exam Action
07/22/22 2:06 AM MDT

 Palpated frontal sinuses: No tenderness reported

Exam Action
07/22/22 2:06 AM MDT

 Palpated maxillary sinuses: No tenderness reported

Exam Action
07/22/22 2:07 AM MDT

Where is the location of headache?

Question
07/22/22 2:07 AM MDT

It’s kind of behind my forehead.

Do you take anything to treat your headaches?

Question
07/22/22 2:09 AM MDT

Yeah. Usually I’ll take a Tylenol and go to bed, and that’ll get rid of it.

What triggers your headaches?

Question
07/22/22 2:09 AM MDT

When I get headaches, it’s usually just from reading. I only get them about once a week and it doesn’t really hurt on one side or the other. The pain is mostly behind both eyes.

When did your vision begin worsening?

Question
07/22/22 2:09 AM MDT

I’m not sure — Maybe over the last year or so.

What makes your blurry vision go away?

Question
07/22/22 2:10 AM MDT

If I stop reading and rest my eyes a bit, then it clears up.

When was your last vision exam?

Question
07/22/22 2:10 AM MDT

I must’ve been… maybe ten the last time the school nurse checked my vision. You know how the school nurses do those little checks every year.

Do you have any allergies?

Question
07/22/22 2:10 AM MDT

Yeah. I’m allergic to cats. And dust, too.

What triggers the eye symptoms? (Clarified to What triggers your symptoms?.)

Question
07/22/22 2:12 AM MDT

It’s a little worse in the morning, but that’s really the only pattern I’ve noticed. (Clarified to what triggers my symptoms.)

Are you taking medication for the itchy eyes?

Question
07/22/22 2:15 AM MDT

No, I haven’t done anything to try to make my eyes less itchy.

Do you have general nose problems?

Question
07/22/22 2:15 AM MDT

Yes, my nose won’t stop running!

Have you had nosebleeds? HEENT Tina Jones Transcript and Documentation

Question
07/22/22 2:18 AM MDT

No.

Do you have frequent sinus congestion? (Clarified to Do you have sinus congestion?.)

Question
07/22/22 2:18 AM MDT

No, I’m not stuffed up — my nose has been running nonstop! (Clarified to if I have sinus congestion.)

Do your allergies trigger your runny nose?

Question
07/22/22 2:19 AM MDT

Well, no. I mean, I never had allergies to pollen or anything outdoors like that. . . But my nose is acting just like my sister’s right now, and she’s always had hay fever. I’m starting to think that this is allergies.

How have you been treating your runny nose?

Question
07/22/22 2:20 AM MDT

I haven’t taken anything. Most of the stuff you get over-the-counter dries me out too much.

Do you take alcohol?

 
HEENT Tina Jones Transcript and Documentation Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation
Model Documentation

Subjective
Ms. Jones is a pleasant 28 years-old African American female presenting to the clinics due to sore/itchy throat and runny nose. The symptoms began 1 week ago. She reports having used over the conter throat drops for her sore throat. Denies treating runny nose at home. She reports it hurts to swallow and rates her throat pain a 3-4/10 . Throat pain is worse at the morning. She has headachhe and blurry vision especially while reading. She denies eye pain. She does not use contacts or glasses. Use of OTC improves headache and vision.

HPI: 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 these symptoms started spontaneously and have been constant in nature. She does not note any specific aggravating symptoms, but states that her throat pain seems to be worse in the morning. She rates her throat pain as 4/10 and her throat itchiness as 5/10. She has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that she has some soreness when swallowing, but otherwise no other associated symptoms. She states that her nose “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. She 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 or 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. Reports headaches while studying. • Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching prior to this past week. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • 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 lymph 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 was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week.

Objective
Ms. Jones is pleasant. She is alert and oriented. She is able to voice needs and her wants. She answers questions appropriately. She is well-groomed and dressed appropriately. She does not appear in any distress at time of assessment. She has allergic shiners and red, chapped skin around her nares. She has a clear postnasal drainage. Moderately erythema. Tonsils are 1+

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with… HEENT Tina Jones Transcript and Documentation

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