Heent Documentation Shadow Health PDF

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Shadow health cardiovascular assignment documentation with description of model documentation...

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10/4/21, 3:32 PM

HEENT | Completed | Shadow Health

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HEENT Results | Turned In Advanced Health Assessment for the APN - Fall 2021, 625 Return to Assignment (/assignments/519372/)

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Overview

Lab Pass (/assignment_attempts/10638471/lab_pass.

Documentation / Electronic Health Record

Transcript Subjective Data Collection

Document: Provider Notes

Objective Data Collection

Document: Provider Notes Education & Empathy Documentation

Student Documentation

https://app.shadowhealth.com/assignment_attempts/10638471

Model Documentation

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10/4/21, 3:32 PM

HEENT | Completed | Shadow Health

Student Documentation

Subjective Ms .Jones is a pleasant 28 year old African American woman who presented to the clinic today with complaints of a runny nose, sore, itchy throat and itchy eyes for the last week. She states these symptoms stared last week and have been constant, with no known exposure to allergens. There are no specific aggravegating symptoms, but her throat hurts worse in the morning. She rates her throat pain as 4/10. She has taken throat drops and drank water to help with the throat pain. She has some pain with swallowing, but no other associated symptoms. She states her runny nose is constant and is clear discharge. She has not taken any medication for her runny nose. She states her eyes are constantly itchy and has not taken any medication for her eyes. She denies cough or any respiratory symptoms. She denies recent illness or exposure to sick individuals. She denies fever, chills, changes in taste, vision, or hearing. She is allergic to cats and dust. Her sister has "hay fever". Social history: She is not aware of any environmental exposures at home or work. She denies dust/mold at her home. She denies use of cigarrettes. Review of Systems: General: denies fatigue, fever, chills. Head: States has headaches after reading for 2+ hours, that are 3/10 Eyes: States that vision has been worsening and compains of blurry vision when reading for 2+ hours. Increased itchyness over past week Ears: denies hearing loss or changes, discharge, or ear pain Nose/sinuses: Denies sinus pressure/pain. States pain on outside of nose from blowing nose often. Mouth/throat: denies dental problems, swollen lymph nodes, or mouth problems. States sore throat began one week ago. Respiratory: Denies shortness of breath or respiratory symtpoms. She has a history of asthma which she uses an inhaler 2-3 times per week for.

Objective General: Ms. Jones is a pleasant, obese 28-year-old African American woman. She is alert and oriented. She is engaged and maintains eye contact throughout the interview and exam. Head: Symmetric, no scalp masses, normal hair, no thinning. Eyes: Bilateral eyes with no lesions, edema, or reddness. Conjuctiva clear. Extraocular movements intact bilaterally. Pupills equal, round, reactive to light bilaterally. Normal convergence. Left fundoscopic exam shows sharp disc margins, no hemorrhages. Right fundoscopic exam shows sharp disc margins and mild retinopathic changes. Left eye vision: 20/20. Right eye vision:20-40. Ears: Shape equal bilaterally, no inflammation in external canals bilaterally, tympanic membranes pearly grey and positive light reflex bilaterally. Rhine, Weber, and whisper test normal bilaterally. Nose: Normal shape, mucosa is pale and swollen bilaterally. No pain with palpation of frontal or maxillary sinuses. Mouth/throat: Pink/moist mucosa, no wounds, good dental hygiene. Tonsils 1+, posterior pharynx erythematous with cobblestoning. Neck: Thyroid is smooth with no nodules or goiter, no lymphadenopathy, mild discoloration of the skin noted. Cartoid pulses +2 with no bruit, no jaw clicks and full range of motion intact. Respiratory: symmetrical chest rise, lung sounds clear and present throughout.

https://app.shadowhealth.com/assignment_attempts/10638471

Model Documentation

HPI: Ms. Jones is a pleasant 28-year-old African American wom who presented to the clinic with complaints of sore, itchy throa itchy eyes, and runny nose for the last week. She states that th symptoms started spontaneously and have been constant in n She does not note any specific aggravating symptoms, but sta that her throat pain seems to be worse in the morning. She rat throat pain as 4/10 and her throat itchiness as 5/10. She has tr her throat pain with occasional throat lozenges which has “help little”. She states that she has some soreness when swallowing otherwise no other associated symptoms. She states that her “runs all day” and is clear discharge. She has not attempted a 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 n exposures to sick individuals. She denies changes in her heari vision, and taste. She denies fevers, chills, and night sweats. S has never been diagnosed with seasonal allergies, but does no that her sister has “hay fever”. Social History: She is not aware of any environmental exposure irritants at her job or home. She changes her sheets weekly an 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 stu • Eyes: She does not wear corrective lenses, but notes that he vision has been worsening over the past few years. She compl of blurry vision after reading for extended periods. Denies incre tearing or itching prior to this past week. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or eara • Nose/Sinuses: Denies rhinorrhea prior to this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinu pressure. • Mouth/Throat: Denies bleeding gums, hoarseness, swollen ly nodes, or wounds in mouth. No sore throat prior to this episod • Respiratory: She denies shortness of breath, wheezing, coug sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization w age 16 for asthma, last chest XR was age 16. Her current inha has been her baseline of 2-3 times per week.

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive light bilaterally. Normal convergence. Left fundoscopic exam re sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right vision: 20/40. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and with positive light reflex bilaterally. Rinne, Weber, and Whisper normal bilaterally. • Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain with palpation of frontal or maxillary sinuses • Mouth/Throat: Moist buccal mucosa, no wounds visualized. Adequate dental hygiene. Uvula midline. Tonsils 1+ and withou evidence of inflammation. Posterior pharynx is slightly erythem with mild cobblestoning. •Neck: No cervical, infraclavicular lymphadenopathy. Thyroid is smooth without nodules or goiter. Acanthosis nigricans presen Carotid pulses 2+, no thrills. Jaw with no clicks, full range of m Bilateral carotid artery auscultation without bruit. • Respiratory: Chest is symmetrical with respirations. Lung sou clear to auscultation without wheezes, crackles, or cough.

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10/4/21, 3:32 PM

HEENT | Completed | Shadow Health

Student Documentation

Model Documentation

Assessment Allergic Rhinitis

Allergic rhinitis

Plan Encourage Ms. Jones to continue monitioring symptoms. Encourage continued fluid intake. Start anti-histamine such as certizine or loratadine 10 mg by mouth daily. Avoid known triggers such as cats or dust. Educate on when to seek further care for episodes involving breathing difficulty, fever, or worsening symptoms. Revisit the clinic in 1 month to follow up.

Encourage Ms. Jones to continue to monitor symptoms and lo episodes of allergic symptoms with associated factors and brin to next visit. • Initiate trial of loratadine (Claritin) 10 mg by mouth daily. • Encourage to increase intake of water and other fluids and ed on frequent handwashing. • Educate on avoidance of triggers and known allergens • Educate Ms. Jones on when to seek care including episodes uncontrollable epistaxis, worsening headache, or fever. • Revisit clinic in 2-4 weeks for follow up and evaluation.

Comments If your instructor provides individual feedback on this assignment, it will appear here.

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