Documentation / Electronic Health Record
Subjective xx
HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of a sore, itchy throat, itchy eyes, and a runny nose for the last week. She describes these symptoms as spontaneous and constant. No specific aggravating symptoms are noted, but she mentions that her throat pain seems worse in the morning. She rates her throat pain as 4/10 and throat itchiness as 5/10. Occasionally using throat lozenges has provided slight relief. Soreness during swallowing is present, but no other associated symptoms. She reports a constant runny nose with clear discharge and itchy eyes. No treatments have been attempted for nasal or eye symptoms. She denies cough, recent illness, changes in hearing, vision, taste, fevers, chills, and night sweats. No history of diagnosed seasonal allergies, but her sister has “hay fever.”
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Social History: No awareness of environmental exposures or irritants at home or work. Weekly sheet changes, no dust/mildew at home. No use of tobacco, alcohol, or illicit drugs. No exercise.
Review of Systems:
– General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats.
– Head: No history of trauma, reports headaches while studying.
– Eyes: No corrective lenses, worsening vision over the past few years, blurry vision after extended reading.
– Ears: No hearing loss, tinnitus, vertigo, discharge, or earache.
– Nose/Sinuses: No previous rhinorrhea, stuffiness, sneezing, itching, allergies, epistaxis, or sinus pressure.
– Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph nodes, or mouth wounds. No previous sore throat.
– Respiratory: Denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. History of asthma, last hospitalization at age 16.
Objective
xx
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. Alert and oriented, maintains eye contact throughout the interview and examination.
Head: Normocephalic and atraumatic. Scalp with no masses, normal hair distribution.
Eyes: Bilateral eyes with equal hair distribution, no lesions, ptosis, or edema. Clear and injected conjunctiva. Intact extraocular movements bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40.
Ears: Equal ear shape. External canals without inflammation. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Normal Rinne, Weber, and Whisper tests bilaterally.
Nose: Midline septum. Boggy and pale nasal mucosa bilaterally. No pain with palpation of frontal or maxillary sinuses.
Mouth/Throat: Moist buccal mucosa, no wounds. Adequate dental hygiene. Midline uvula. Tonsils 1+ without inflammation. Slightly erythematous posterior pharynx with mild cobblestoning.
Neck: No cervical, infraclavicular lymphadenopathy. Smooth thyroid without nodules or goiter. Acanthosis nigricans present. 2+ carotid pulses, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit.
Respiratory: Symmetrical chest with clear lung sounds, no wheezes, crackles, or cough.
Assessment
xx
Allergic Rhinitis
Plan
xxx
Encourage Ms. Jones to continue monitoring symptoms and log episodes of allergic symptoms with associated factors for the next visit. Initiate a trial of loratadine (Claritin) 10 mg orally daily. Encourage increased fluid intake and frequent handwashing. Provide education on avoiding triggers and known allergens. Instruct Ms. Jones on when to seek care, including episodes of uncontrollable epistaxis, worsening headache, or fever. Schedule a follow-up clinic visit in 2-4 weeks for evaluation.
HEENT Documentation HPI: Ms. Jones
Documentation / Electronic Health Record
Document: Provider Notes
| Student Documentation | Model Documentation |
|---|---|
Subjectivexx |
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. |
Objectivexx |
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 equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Rinne, Weber, and Whisper tests 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 without evidence of inflammation. Posterior pharynx is slightly erythematous with mild cobblestoning. •Neck: No cervical, infraclavicular lymphadenopathy. Thyroid is smooth without nodules or goiter. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation without wheezes, crackles, or cough. |
Assessmentxx |
Allergic Rhinitis |
Planxxx |
Encourage Ms. Jones to continue to monitor symptoms and log her episodes of allergic symptoms with associated factors and bring log to next visit. • Initiate trial of loratadine (Claritin) 10 mg by mouth daily. • Encourage to increase intake of water and other fluids and educate on frequent handwashing. • Educate on avoidance of triggers and known allergens • Educate Ms. Jones on when to seek care including episodes of uncontrollable epistaxis, worsening headache, or fever. • Revisit clinic in 2-4 weeks for follow up and evaluation. Dont wait until the last minute.Provide your requirements and let our native nursing writers deliver your assignments ASAP. |