HEENT Physical Assessment Assignment Results | Completed
Advanced Health Assessment - Chamberlain, NR509
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Lab Pass
Subjective Data Collection: 25 of 28 (89.3%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Patient Data
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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 symptoms
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
Confirmed allergies Reports known allergy to cats Reports known allergy to dust Reports no previous problems with
seasonal allergies
Review of Systems
Asked about general symptoms Denies recent or frequent illnesses
Denies chills Denies fever
Reports low energy level Denies nausea or vomiting
Asked about review of systems for head Reports occasional headaches
Denies current headache Denies history of head injury Denies lightheadedness
Followed up on headaches Headaches occur once a week
Headaches last "a few hours"
Describes headaches as tight and throbbing
Describes headache location as behind her forehead
Rates headache pain as a 3 or 4 Reports treating headaches with Tylenol Reading and studying seem to cause
headaches
Asked about review of systems for eyes Reports occasional blurry vision
Reports worsening vision Denies eye pain
Denies dry eyes
Reports last vision exam was in childhood Does not use corrective lenses
Followed up on vision problems Describes blurry vision as "fuzzy letters"
Blurry vision occurs when reading for long periods
Blurry vision occurs after 2+ hours of reading
Reports that blurry vision and headaches often coincide
Asked about review of systems for ears Denies general ear problems
Denies change in hearing Denies ear pain
Denies ear discharge
Reports last hearing test was in childhood
Asked about review of systems for nose Denies change in sense of smell
Reports no nasal or sinus surgeries Denies nosebleeds
Asked about review of systems for mouth and jaw
Denies general mouth problems Denies change in sense of taste Denies dry mouth
Denies history of oral surgery Denies mouth pain
Denies mouth sores Denies gum problems Denies tongue problems Denies jaw problems
Asked about review of systems for dentation
Denies current dental problems Reports visit within the last 2 years Reports regular visits in childhood Reports a few cavities in childhood
Asked about review of systems for neck, throat and glands
Denies history of recurrent strep throat Denies lymph node problems
Denies history of general throat problems Denies voice changes
Denies history of tonsil problems Denies general neck pain
Family History
Asked about relevant family history Reports sister with hay fever
Denies family history of vision problems Denies family history of sinus problems Denies family history of ear or hearing
problems
Denies family history of mouth, throat, or gland problems
Denies family history of headache or migraine
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