SOAP Note Tina Jones HEENT Subjective: ID: 28-year-old African American Female who is employed as a supervisor at MidAmerican Copy & Ship. CC: Runny nose, sore itchy throat, itching eyes HPI: Tina Jones is a 28-year-old African American female who presented with a sore and itchy throat, runny nose, and itchy eyes that

SOAP Note Tina Jones HEENT Subjective: ID: 28-year-old African American Female who is employed as a supervisor at MidAmerican Copy & Ship. CC: Runny nose, sore itchy throat, itching eyes HPI: Tina Jones is a 28-year-old African American female who presented with a sore and itchy throat, runny nose, and itchy eyes that began a week ago. She reports symptoms are stable with no increase in severity except for her sore throat, which is worse in the morning. She has difficulty swallowing due to a sore throat and a constant runny nose. Nasal drainage is clear with no smell. She has been utilizing lozenges with some relief. She has not used anything for her nose or eye symptoms, and she rates her throat pain as 4/10 and her throat itchiness as 5/10. She denies fever, chills, or night sweats and denies any recent illness. She denies exposure to sick individuals. She denies a history of seasonal allergies. Past Medical History: She was diagnosed with asthma at 2-year-old. Asthma is controlled; she reports using her inhaler 2-3 times a week. The patient reported her last hospitalization was during her high-school years for an asthma exacerbation. She was diagnosed with type 2 diabetes when she was 24 years old. Her diabetes is uncontrolled per her reports of not taking prescribed metformin. Family history: This study source was downloaded by 100000889694653 from CourseHero.com on 09-30-2024 00:03:05 GMT -05:00