NSG 500 DISCUSSION IV; HEENT ASSESSMENT ON TINA

NSG 500 MODULE IV DISCUSSION; HEENT ASSESSMENT
USE THE INFORMATION BELOW TO WRITE YOUR WEEKLY DISCUSSION, FIRST PAGE IS STUDENT DOCUMENTATION AND THE SECOND PAGE IS THE MODULE. USE THIS INFORMATION AND ANSWER THE DISCUSSION QUESTION. Using the information from your HEENT examination of Tina Jones in Shadow Health, write a SOAP note and copy it into the Discussion for Module IV. Your response discussion should be a review of one other student's SOAP note, commenting on identifying areas that you did not include in your own SOAP note and discussing why inclusion of those areas may be important in reaching an appropriate assessment.  Post your initial response AND. Respond to one student Both responses should be scholarly written, APA formatted, and referenced.  A minimum of 2 references are required  STUDENT RESPONSE BELOW:
Objective Ms Jones is a 28-year-old woman well-groomed who present to the clinic today with compliant of sore throat and running nose, and itchiness at the back of the throat which started one week ago. She is allergic to penicillin, cats, and dust. PMH: diabetic and HTN, asthma. No triggers identified. She is alert and oriented and answers questions willingly.
Assessment Pt. denies chest congestion or cough, denies sinus pressure/headache, denies ear pain. on assessment, pt. has temperature of 99.1. Head symmetrical, no visible abnormalities, eyes in normal appearance with no abnormalities, conjunctiva pink and moist, no drainage. Ears in position with no abnormalities. Nasal canal with no abnormalities noted pink in color. Ears in correction position, no abnormalities, no hearing lost. pink and Bilat eyes symmetrical, no discharge. Oral mucosa moist and pink, tonsils with no abnormalities. Post-nasal drip with no discharge. Face appears normal with no deformity. On palpation, there is no tenderness or additional abnormalities. All arteries WNL and intensity 2+. No palpable abnormalities on jaw. No sinuses present. Lymph nodes not palpable nodes head, neck, axillary and supraclavicular. LSC on auscultation, no adventitious sounds. All arteries WNL, no bruit. PERRL.Vision adequate. Weber, whisper and Rinne test normal.
Plan Pt. is possible suffering from allergic rhinitis. Plan is to include avoid pollen and nasal cleansing. Start cetirizine 10 mg Po daily, Acetaminophen 650 mg PO Q4hrs PRN for fever. Continues with inhaler for asthma. Weight loss program. Warm wet cloth to face 4-6/day for comfort. Flonase nasal spray two sprays into each nostril once daily. Report back to clinic if symptoms get worse. Coughing, night sweats, chest congestion. Chest-ray if symptoms persist.

MODULE RESPONSE BELOW/WHAT SHOULD HAVE BEEN DONE.

SUBJECTIVE DATA:

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 2-3 times a week.

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.

ASSESSMENGT: Allergic Rhinitis

PLAN:

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.