Mallory Zabor

NURS 60015
Kent State University

Episodic Visit

Your Name: Tina Jones

Source and Reliability:

SUBJECTIVE

 
Chief Complaint (CC): Patient arrives to clinic with nose, throat and eye complaints stating “it
seems more like allergies than a cold.” Patient reports sore and itchy throat, runny nose and itchy eyes
for one week that are “not getting worse but not going away.”

History of Present Illness (HPI):  28 year old, African American heterosexual female presenting with
complaints of sore and itchy throat, runny nose and itchy eyes which she states have all been going on for
a week. Sore throat is worse in the morning and is exacerbated by swallowing. Reports throat pain as
being constant with severity being mild to moderate (4/10); with Relieving factors being throat lozenges
and water. Reports runny nose to be constant and yet denies sinus pain, pressure, as well as, sneezing and
itchy nose. Discharge from nose per patient is clear and thin and non-purulent. Patient also reports eye
itchiness and redness however, denies affect on her breathing and no current wheezing even with her
history of asthma. Denies chest pain, fever, fatigue and shortness of breath. Patient allergic to cats and
dust however, patient has not been around cats for a month. Patient has not been needing her inhaler any
more than usual with her current illness.

Past Medical History (PMH): 

Asthma: Diagnosed ~ age 2 1/2, requires 2 puffs of albuterol for s/s (wheezing) 2-3 X per week, well
controlled, never intubated for episode, last exacerbation around 16-17 where she required breathing
treatment in hospital with about 5 total asthma hospitalizations as a child and teen. Triggers of asthma are
cats, dust and running up and down steps.

DM2: Diagnosed at 24, does not check blood sugars at home, recent ER visit increased glucose, was on
metformin but DC’d 3 years ago r/t side effects Gassy. To control DM2 she reports that she stays away
from soda and sweets and instead drinks diet soda.

Past Surgical History (PSH): Reports no past surgical history

Medications: 
Throat lozenges: one every few hours to comfort throat pain
Tramadol: 50 mg PO, TID PRN foot pain
Acetaminophen: 500-1000 mg PO PRN headaches
Ibuprofen : 600 mg PO TID PRN menstrual cramps
Albuterol: 90 mcg/spray MDI 2 puffs Q4H PRN Wheezing: “when around cats,” also dust; last use three
days ago
Metformin: Dose unknown, DC’d due to Side effects (gas mainly), last taken about 3 years ago
Mallory Zabor
NURS 60015
Kent State University

Patient denies use of vitamins and/or herbal supplements

Allergies: DRUG: Penicillin: rash, hives, last reaction as child; ANIMAL: CATS watery, itchy eyes,
asthma exacerbation; ENVT: Dust: sneezing, wheezing, itchy eyes

Immunizations: Not currently vaccinated for flu, received all vaccinations as a child, pneumonia
vaccine several years ago. Tetanus about a year ago.

Family Hx:  Pertinent to Diagnosis: Sister: Hay fever and every Spring she sneezes and her nose runs so
she takes an OTC medication.

Denies family history of vision problems, ear or hearing problems, mouth, throat or lymph node
problems, headaches/migraines, and sinus problems.

Mother, 50 y/o: HTN, HLD

Father, deceased at 58 r/t car accident: HTN, HLD, DM2
Brother, 25 y/o: Obesity
Sister, 14 y/o: Asthma, never intubated
Paternal grandmother, 82: generally well health other then controlled HTN
Paternal grandfather, deceased in mid-sixties r/t Colon CA: DM2, HTN
Maternal grandmother, deceased 73 r/t stroke: HTN, HLD
Maternal grandfather, deceased 78 r/t stroke: HTN, HLD
Paternal Uncle: Addiction, alcoholism

Social Hx: Patient single, no children. Left monogamous relationship 2 years ago. Works at a shipping
company where she has been since high school and has just been promoted to supervisor. She is currently
a part-time student to obtain bachelors in accounting, pays for school out-of-pocket. Denies financial and
transportation concerns and can afford medication however, patient does not regularly check her blood
sugar at home and tries to avoid the doctor at all costs due to associated out-of-pocket costs. She was
started on metformin however, she disliked the side-effects r/t gas and discontinued about 3 years ago.
She also did not like checking her blood glucose at home. No current diabetic regime in place and last
visit for foot injury glucose was elevated. Patient Lives with her mother and 14 year old sister where she
moved back home to help with bills when her father passed away in a care accident. Patient does provide
care for her mother and sister some of the time however, due to her recent foot injury about a month ago
she had needed support from them however, is back to baseline. Support system based in family and
heavy church involvement. Wears a seatbelt in the car. Per patient, total number of partners is 3 and when
patient is sexually active does not use condoms 100% of the time, no previous abortions or pregnancies,
not currently on birth control as patient is not currently sexually active. Never had a mammogram, last
pap and STI testing was normal and was about 4 years ago.

Tobacco: Patient denies current and past cigarette smoking.

Alcohol: Drinks socially, few drinks per week.

Mallory Zabor
NURS 60015
Kent State University

Drugs: No current illicit drug use, brief marijuana use years ago, last marijuana use around 21.
Patient denies use of psychedelics.

Review of Systems (ROS): Pertinent to CC

General: Patient denies fatigue, fever, chills, night-sweats and recent weight loss.

Head: Patient complains of Headaches once per week which are brought on by reading/studying for
approximately 5-6 hours. Pain is felt behind bilateral eyes “kind of behind my forehead” and rates head
ache pain 3-4/10 and describes as a tight throbbing pain. Headaches last a few hours and are relieved by
sleep and Tylenol (one 500mg extra strength). Denies History of head injury, denies
lightheadeness/dizziness, denies current Headache.

Eyes: Blurry vision complaints with reading “fuzzy letters.” Blurry vision occurs about 2 hours after
reading. Reports worsening vision with no recent eye exam (since child). Denies eye pain and use of
corrective lenses/contacts. Reports eyes itching constantly, as well as, eye redness.

Ear: Denies general ear problems, ear pain, change in hearing and ear discharge.

Nose: Patient reports thin clear discharge, as well as, post-nasal drip. Denies itchy nose, sinus
pain/pressure and sneezing. Denies changes in smell, no nasal/sinus surgeries, and nosebleeds.

Mouth: Denies teeth and gum problems, dry mouth, history of oral surgery, mouth pain or sores, change
in taste, tongue or jaw problems. Denies current dental problems however, last exam was as a child and
only was treated then for cavities.

Throat: Patient complains of sore throat X 1 week, worse in the morning and exacerbated by swallowing
and soothed by drinking water and lozenges. Patient states her throat is “not getting worse but not going
away.” Complaints of post-nasal drip. Denies history of strep throat, lymph node problems, voice
changes, tonsil issues.

Pulmonary: Patient has no current complaints of wheezing or exacerbations of asthma with current
illness. Denies cough and chest pain or tightness. Denies wheezing. Negative for coughing up mucus
however patient noted post-nasal drip and clear drainage from nares.

Cardiac: No complaints of chest pain, no SOB, no heart palpitations or swelling of limbs reported.

OBJECTIVE

Physical Exam:

Head: Head symmetrical, maxillary and frontal sinuses negative for tenderness

Eyes: Sclera positive for injection, PERRL, conjunctiva moist and pink, vision tested with left eye being
20/30 and right eye being 20/40, opthalmoscope reveals right retinal cotton wool bodies whereas left
retina appears normal with defects. Both right and left eye appear to have sharp disc margins. Cardinal
fields and convergence are negative for abnormality.
Mallory Zabor
NURS 60015
Kent State University

Nose: Bilateral nares negative for erythema, bilateral turbinates patent, positive for clear mucus, no
foreign body,septum appears midline and unperforated, no lesions visible, negative for polyps, outer nares
and surrounding area of nose appears irritated and chapped and erythema is noted.

Mouth: oral mucosa moist and pink, tonsils grade +1 edema, posterior oropharynx with cobblestone
appearance, positive for clear post nasal drip, tongue appears midline without white patches, redness or
irritation. Positive gag reflex.
Lungs: All fields reveal no adventitious lung sounds both anterior and posterior.

Cardiac: UTA however, carotid and temporal arteries negative for bruit or thrill and +2 as expected

VS:
170 cm, 89 kg = BMI: 30.8
Random glucose: 199
Temperature: 99.1*F
BP: 141/82
HR: 80
RR:16
SpO2: 99%

ASSESSMENT/IMPRESSION:

Differential Diagnoses:

Diagnosis: Hay Fever/ seasonal allergic rhinitis

1) Strep throat

2) Viral (non-allergic) Rhinitis

3) Sinus Infection

Problem List:

 Asthma, controlled with inhaler, exacerbated by cats, dust and running up steps
 Diabetes Type II, non-compliant with medications
 Family History of Hay fever
 Current Complaint: Patient arrives to clinic with nose, throat and eye complaints stating
“it seems more like allergies than a cold.” Patient reports sore and itchy throat, runny
nose and itchy eyes for one week that are “not getting worse but not going away.”
Mallory Zabor
NURS 60015
Kent State University

PLAN:

Labs: In-office rapid strep, CBC with diff, IgE, allergy panel

Referral to allergist/immunologist for further allergy testing/immune panel and more complete work-up
of symptoms.

CT scan of head for sinuses due to post-nasal drip and complaints of HA behind eyes and forehead. Wait
for read and refer to ENT as needed based upon results.

Prescribe 10 mg once per day Montelukast to improve asthma and allergies. OTC medications for
allergies including 10 mg cetirizine once per day in morning, as well as, flonase nasal spray once per day
in morning. Throat pain OTC Chloraseptic spray. Continue with throat lozenges PRN. Recommend
Mucinex DM if mucus becomes thick. Recommend nasal saline irrigation sold over the counter to
improve post-nasal drip symptoms and clear out sinuses of possible allergens.

Educate patient on soothing sore throat: Hot tea with lemon and honey, steamy shower, salt water gargle.

Educate patient on when to return and to monitor temperature at home and if increase in temperature or
any new or concerning symptoms to call the office to consult plan of care during office hours or if after
hours and symptoms are concerning enough that they cannot wait to go to ER. If mucus becomes thick
and changes color and symptoms do not improve in one week call office for follow-up appointment.

Educate patient on changing and washing sheets and pillow cases at least once per week and also
investing in some allergenic pillow and mattress covers to improve allergies to dust. Recommend patient
to avoid allergen triggers if possible, as well as, avoiding cigarette smoke.

Follow-up with me if symptoms do not improve or worsen in one week. Otherwise schedule follow-up in
one month after tests have been completed to reconvene on improvements and more definitive diagnosis.