Subjective

HPI: Ms.Jones is a 28 years olf african american women who is presented to the clinic with complaints of sore, itcy throat and running nose that wont stop for one week . She states that the throat pain is bad and rates it a 4/10 . she states that she has treated her throat pain with occcasional throat lozenges which has ” helped her a little” . patient mentions that it hurts to swallow and that her eyes are itchy . she denies taking anything to stop her nasal irritation and ichy eyes. patient denies exposure to sick individuals , denies symptoms of fever and chills. patient has never been diagnosed with seasonal allerges but states that her sister has ” hay fever” Social History: patient is unaware of any environmental exposure / irritants . she mention that she keeps the house ” pretty clean” . patient mentions that she used” pot when in highschool,and after highschool but definitely dont anymore ” she states she hasnt smoked pot since she was twenty one. patient does not excersie however is on her feet most of the time at work . Review systems : General – denies changes in weight, fever and chills. Head: denies history of trauma but mentions headches due to studying that last a few hours, takes Tylenol to help allivate pain. Eyes- patient denies wearing glasess or contacts however notes the vision is sort of blurry when reading and is currently getting worse Ears- denies hearing loss, tinnitus,vertigo or discharge. patieny states that her ears are ” fine” Nose- Denies any problems with nose proior to this issues, denies getting stuffiness, sneezing, previous allergies prior Mouth- denies bleeding gums, hoarseness, swollen lymph nodes Respirtory- patient denies shorness of breath, cough, history of tuberculosis, or bronchitis, patient has asthma and uses inhaler 2-3 times per week . He last chest x-ray wass in highschool .

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 or headaches. • 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

patient c/o 4/10 pain in her throat, has been using drops and tylenol ovet the counter for pain patient also c/o headaches when reading or doing homework, hasn’t had an eye exam in years. Patient’s head normocephalic, acne bialaterally to cheeks. Eyes watery with clear drianage, PERRLA. Vision 20/20 in left and 2/30 in the right eye. patent reports blurry vision at times, when reading, denies glasses or contacts. Nares appear to be swollen, patient denies diffculty breathing, states that hher norse has been “runny” with clear drainage. patient denies any issues with hearing. Tympanci memrane intact and pink bilaterally. Mouth erythrmic with cabblestoning, gag reflex intact. Visible drainage- Clear. Denies dizziness, problems with gum, sinus infection or any recent cold symptoms. Patient denied any neck pain or stiffness- no palpable nodes on exam. Lungs sounds clear. Denies any shortness of breath/ diffculty breathing General : Patient Ms. Joes is a 28 year old aferican american women. o acute distress identified. Patient is alert and oriented. She maintains eye contact throughout examination/asessment Head: head is normocephalic and atraumatic. Scalp has no masses , normal hair distribution. Eye: Bilateral with equal hair distriibution,no lesions, no ptosis, no edma, conjectivia clear and injected. Extraocular movements intact bilateral. Pupils equal, round nad reactive bilaterally. Normal convergence. Left fundoscopic exam revals mild retinopathic changes. Left eys 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. Reinne, weber and wisper test was normal bilaterally. Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain palpations of frontal or maxillay sinuses Mouth/ throat – Moist buccal muccosa, no wounds identified. Adequate dental hygiene. Uvula midline. Tonsils 1 + and without evidence of inflammations. Posterior pharynx is slightly erythematous with mild cobblestoning Neck : No cervical, infraclavicular lymphadenopathy. Thyriods is smooth without nodules or goiter carotid pulses 2, no thrill . Jaw with no clicks, full range of motion. Bilateral carotid arty auscultation without bruit . Respirtory : Chest is symmetricall with respirations. Lungs sounds clear to ausculttion without wheezes, crackles or cough. No evidence of shortness of breath

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.

Assessment

patient was acessed for sore throat and runny nose Inspection of the Head, eyes, nasal cavities, Ears, Mouth, Neck Palpation of the scalp, sinuses, temporal arteries, carotid arteries, Jaw, Lymph nodes, Thyroid Ascultation of breath sounds, Temporal arteries, and carotid arteries

Allergic Rhinitis

Plan

Refer patient for medical specialist examinination. Refer patient to ophthaltmologist for eye exam Rapid strep test obtained and throat culture for strep throat Possible need for antibitics however lab results required (culture and sensitivity rerquired ) Encourage Ms. Jones continues to monitor symptoms and cahrt episodes of allergic symptoms and other associated factors Start LORATADNE 10MG PO per MD order. Encourage fluid intake and proper hand hygiene Educate patients of techiques to aviod triggers and signs and symptoms to report Educates patient to seek advane care for worsening headaces or fever Refer patient for follow up evaluation in two weeks after reassessment by the physcian .