HEENT Assessment
Patient: MR
Age: 28
Gender: Male
S:
CC: “My throat really hurts”
HPI: Patient presents to the office c/o a sore throat that has been
going on for three days. Patient states his throat is worse upon
wakening in the morning and is better when he takes Halls cough
drops. Patient denies trying any other OTC medications to help his sore
throat. Patient states his tonsils have been removed and since then his
throat issues have resolved. This is his first episode of a sore throat
since the removal in January 2015. Patient denies throat irritation from
food or drink, and states that warm tea has helped his pain. Patient
rates pain in throat 8/10 upon wakening and states the pain drops to a
5/10 as the day progresses. Patient denies any seasonal allergies.
Patient denies difficulty swallowing, runny or stuffed nose, ear pain,
sinus pain, headache, and watery eyes. Patient denies any sick
contacts or travel out of the country. Patient denies taking any
prescription medications, vitamins, supplements, herbals, or over the
counter medications at this time.
PMH: Patient has a past medical history of chicken pox, and tonsillitis
and underwent a tonsillectomy in 2015.
FH: Patient’s father has a history of heart disease, high blood pressure,
and high cholesterol. Patient’s mother has a history of hypothyroidism
and gestational diabetes. Patient denies any other family history of
head, ear, eye, nose, throat cancers, problems or surgeries.
SH: Patient is a nonsmoker, nondrug user, and consumes 1-2 beers per
week. Patient participates in a regular exercise regimen 3-4 days per
week. Patient is married and is sexually active.
ROS:
General: Pt denies any recent weight changes, weakness,
fatigue or
fevers.
Skin, hair, nails: Pt denies any instances of rash, lumps, sores,
itching, dryness, or color changes. Pt denies any changes to his
hair or nails.
Head: Pt denies headache, head injury, or dizziness.
Patient: MR
Age: 28
Gender: Male
S:
CC: “My throat really hurts”
HPI: Patient presents to the office c/o a sore throat that has been
going on for three days. Patient states his throat is worse upon
wakening in the morning and is better when he takes Halls cough
drops. Patient denies trying any other OTC medications to help his sore
throat. Patient states his tonsils have been removed and since then his
throat issues have resolved. This is his first episode of a sore throat
since the removal in January 2015. Patient denies throat irritation from
food or drink, and states that warm tea has helped his pain. Patient
rates pain in throat 8/10 upon wakening and states the pain drops to a
5/10 as the day progresses. Patient denies any seasonal allergies.
Patient denies difficulty swallowing, runny or stuffed nose, ear pain,
sinus pain, headache, and watery eyes. Patient denies any sick
contacts or travel out of the country. Patient denies taking any
prescription medications, vitamins, supplements, herbals, or over the
counter medications at this time.
PMH: Patient has a past medical history of chicken pox, and tonsillitis
and underwent a tonsillectomy in 2015.
FH: Patient’s father has a history of heart disease, high blood pressure,
and high cholesterol. Patient’s mother has a history of hypothyroidism
and gestational diabetes. Patient denies any other family history of
head, ear, eye, nose, throat cancers, problems or surgeries.
SH: Patient is a nonsmoker, nondrug user, and consumes 1-2 beers per
week. Patient participates in a regular exercise regimen 3-4 days per
week. Patient is married and is sexually active.
ROS:
General: Pt denies any recent weight changes, weakness,
fatigue or
fevers.
Skin, hair, nails: Pt denies any instances of rash, lumps, sores,
itching, dryness, or color changes. Pt denies any changes to his
hair or nails.
Head: Pt denies headache, head injury, or dizziness.
