NUR 634 Topic 3 Shadow Health Assignment; HEENT
- $25.00
Chief complaint
“My throat has been sore and itchy. Any my nose won’t stop running” History of Presenting Illness
Tina Jones is 28 y/o African American female with a history of allergies and asthma presenting to the clinic complaining of a sore, itchy throat, a runny nose, and itchy eyes that has been lasting one week. She rates her throat pain a 5/10. Her symptoms are constant and while nothing makes them better, they seem to be worse in the morning. She describes her throat pain as moderate and constant. She also explains that swallowing makes her throat hurt worse. She is treating her throat pain with lozenges which she feels have helped a little. Her nose runs all day, and the drainage has been clear and thin. Her eyes have been itchy, but she states that she doesn’t like eye drops and that cold medicine dries her up. She denies cough and shortness of breath. She denies any changes to her hearing but feels like she has noticed her vision to be slightly blurry.
She is up to date on all her immunizations. She lives with her mother and has health insurance through her job as a supervisor at mid-American copy and ship.
Medical History
Asthma: Diagnosed at 2.5y/o uses an inhaler PRN and claims it to be not as bad as when she was a kid. States that she has to go to the hospital for her asthma when she was a kid.
Diabetes: Diagnosed at 25y/o. She does not take medication for it but manages it by watching what she eats and avoiding sweets
Scrapped foot and which got infected one month ago-unknown treatment plan Surgical History
No surgical history Family History
Mother: 50y/o. History of Hypertension and high cholesterol
Father: Passed away last year at 58 y/o due to a MVA. History of Hypertension, high cholesterol, and diabetes
Paternal Grandfather: Passed away in his 60’s from colon cancer. History of diabetes. Paternal Grandmother: 82 y/o. History of Hypertension and high cholesterol
Maternal Grandmother: Passed away at 73y/o from a stroke. History of Hypertension and high cholesterol
Maternal Grandfather: Passed away at 78y/o from a myocardial infarction. History of Hypertension and high cholesterol.
Sister: 14 y/o. History of Hay fever and asthma Brother: 25y/o. No medical history
Social History:
She denies use of tobacco. Denies use of illicit drugs. She does drink alcohol 1-2x/wk socially. Allergies
Cats, dust, PNC Home Medications
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