NURS 520>TINA JONES TRANSCRIPT HEENT Advanced Health Assessment - Clinical Completed Shado, Exams of Nursing

Download NURS 520>TINA JONES TRANSCRIPT HEENT Advanced Health Assessment - Clinical Completed Shado and more Exams Nursing in PDF only on Docsity! 4/4/202 0 HEENT | Completed | Shadow Health 1/17 HEENT Results | Turned In Advanced Health Assessment - Clinical Replacement, NURS 520 Return to Assignment (/assignments/316001/) Your Results Lab Pass (/assignment_attempts/6391605/lab_pass.p Overview Transcript Subjective Data Collection Objective Data Collection Transcript Started: Mar 27, 2020 | Total Time: 82 min 4/4/202 0 HEENT | Completed | Shadow Health 2/17 Well, no. I mean, I never had allergies to pollen or anything outdoors like that. . . But my nose is acting just like my sister's right now, and she's always had hay fever. I'm starting to think that this is allergies. (Clarified to if I have had these symptoms My itchy eyes, runny nose, and sore throat all started a week ago. [AUDIO COMING SOON] All Lines (203) Interview Questions (119) Statements (12) Exam Actions (72) Education & Empathy Documentation Gree 03/27/20 7:31 PM ED Hey. What brings you in today Questio 03/27/20 7:31 PM ED My throat has been sore... and itchy. And my nose won't stop running. These symptoms are driving me nuts. Empathiz 03/27/20 7:32 PM ED Thanks for saying that. Questio 03/27/20 7:33 PM ED February 17th. (Clarified to what is my birth date.) How old are you Questio 03/27/20 7:33 PM ED I'm 28. Questio 03/27/20 7:34 PM ED Questio 03/27/20 7:34 PM ED How severe is your sore throat Questio 03/27/20 7:35 PM ED Have you had this problem before (Clarified to Have you had these symptoms before?.) Miss Jones what is your birth date (Clarified to What is the date of your birth?.) I'm sorry to hear that you are not feeling well today. Let us see what we can do to help these symptoms improve Hello Miss Jones I'm Amor, an NP student. I will be interviewing you and examining you today. Is that ok How long have you had these symptoms Do you take other over-the-counter medications other than Proventil I've been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often. Thanks for telling me. It is important to keep me updated on all medications that you take, even over the counter drugs. Medications can interact with each other and can be toxic Thanks for telling me. Often do you use your inhaler I don't use it every day. I used it last week, I think. Do you have asthma Yeah, I do. Can you describe your asthma symptoms My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs. How severe your asthma symptoms (Clarified to How severe is your asthma?.) My asthma has been pretty under control. I use my inhaler a few times a week and it helps. (Clarified to how severe my asthma is.) Have you been hospitalized before I used to go to the hospital for asthma growing up, but I hadn't been in a while until about a month ago. . . I had to go to the ER for my foot. When was the last time you were hospitalized with asthma (Clarified to When was your last hospitalization for asthma?.) I used to go to the hospital alot, for asthma attacks, but not since I was sixteen. (Clarified to when my last hospitalization for asthma was.) Why do you go last message to the hospital I had to go to the ER a little over a month ago for my foot. . . before that, I hadn't gone since I was sixteen. HEENT | Completed | Shadow Health 4/4/202 0 5/17 Tell me more what happened in your foot last month (No matching questions found.) what happened to your foot last month I scraped it up pretty bad a while ago. It got infected, too. [AUDIO COMING SOON] Questio 03/27/20 7:42 PM ED Educat 03/27/20 7:43 PM ED Questio 03/27/20 7:44 PM ED Questio 03/27/20 7:44 PM ED Questio 03/27/20 7:44 PM ED Questio 03/27/20 7:45 PM ED Questio 03/27/20 7:45 PM ED Questio 03/27/20 7:45 PM ED Questio 03/27/20 7:45 PM ED Questio 03/27/20 7:46 PM ED Questio 03/27/20 7:46 PM ED I am glad to hear that your foot is getting better Thanks for understanding. Do you have any allergies Yeah. I'm allergic to cats. And dust, too. What do you use to improve your eye symptoms All I've done is suck on some throat drops. And I've been drinking more water, which helps. Does anything help with your itchy eyes No, I haven't done anything to try to make my eyes less itchy. Are you exposed to allergens at work No, I don't notice any symptoms getting worse at work. Have you ever had a sore throat like this before Yes, my throat's sore right now. do you Have any other symptoms Let's see... I have a lot going on so here's the laundry list: sore and itchy throat, runny nose, itchy eyes. When do you get the headaches When I get headaches, it's usually just from reading. I only get them about once a week and it doesn't really hurt on one side or the other. The pain is mostly behind both eyes. Would you rate this headaches and a scale of 1 to 10 Not too bad. . . I'd say about 3. Or a 4 if I really push it. What helps your headaches HEENT | Completed | Shadow Health 4/4/202 0 6/17 I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON] Does anything make your headache worse Usually they get worse if I don't stop studying. I try to take a break when they start most of the time, but if I have a test or something coming up, I just have to try and ignore it. Empathiz 03/27/20 7:46 PM ED Questio 03/27/20 7:47 PM ED Questio 03/27/20 7:47 PM ED Questio 03/27/20 7:47 PM ED Questio 03/27/20 7:48 PM ED Questio 03/27/20 7:48 PM ED Questio 03/27/20 7:48 PM ED Questio 03/27/20 7:48 PM ED Questio 03/27/20 7:48 PM ED Questio 03/27/20 7:49 PM ED Questio 03/27/20 7:49 PM ED You take any vitamins No, I don't take any vitamins. Do you take any herbal supplements No, I don't take anything herbal. Have you been to the eye doctor recently No, I haven't been to an eye doctor since I was a kid. When was the last time you went to the eye doctor I must've been... maybe ten the last time the school nurse checked my vision. You know how the school nurses do those little checks every year. Do you remember the result for your vision test at school (No matching questions found.) Do you have any problems with your mouth No. You have any problems with your teeth No, I've got good teeth. They don't give me any problems. Do you have any other medical problems I have diabetes and asthma, but I can't even deal with those today. Are you taking any diabetic medications I don't take anything for my diabetes anymore. what Medicine were you prescribed for diabetes It was Metformin. HEENT | Completed | Shadow Health 4/4/202 0 7/17 Tell me more on why you stopped metformin (No matching questions found.) why you stop metformin I just got sick of dealing with it! Questio 03/27/20 7:49 PM ED Questio 03/27/20 7:49 PM ED Questio 03/27/20 7:50 PM ED Questio 03/27/20 7:50 PM ED Questio 03/27/20 7:50 PM ED Questio 03/27/20 7:51 PM ED Questio 03/27/20 7:51 PM ED Questio 03/27/20 7:51 PM ED Questio 03/27/20 7:51 PM ED Questio 03/27/20 7:51 PM ED Questio 03/27/20 7:52 PM ED Questio 03/27/20 7:52 PM ED Do you drink alcohol I do sometimes, yeah, when I go out with my friends. How much alcohol do you drink I only have a few drinks when I go out. What type of alcohol do you drink I usually get rum and diet Coke. I don't know why that matters. Different drinks have different alcohol levels Alright, thanks for letting me know. How many alcohol drinks do you take in a month (Clarified to How many drinks do you have per month?.) Oh, I don't know. Let's see... I might go out every few weeks, so twice a month... and I maybe have 2 or 3 drinks at a time, so maybe 6 drinks a month. Even if I go out more than usual, no more than ten. (Clarified to how many alcoholic drinks I have a month.) Do you use any recreational drugs No. Are you involved in a stable relationship (Clarified to Are you currently in a relationship?.) Um, not right now. (Clarified to if I am in a relationship.) What is your family medical history My mom has some issues, and I think some of my grandparents did, too. When were you diagnosed with diabetes I was diagnosed when I was 24. HEENT | Completed | Shadow Health 4/4/202 0 10/1 When were you diagnosed Asthma My doctor told me when I was pretty little. . . I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then. Where do you live Questio 03/27/20 8:03 PM ED Questio 03/27/20 8:03 PM ED Questio 03/27/20 8:03 PM ED Educat 03/27/20 8:03 PM ED Questio 03/27/20 8:03 PM ED Questio 03/27/20 8:04 PM ED Questio 03/27/20 8:04 PM ED Questio 03/27/20 8:04 PM ED Questio 03/27/20 8:05 PM ED Questio 03/27/20 8:05 PM ED Questio 03/27/20 8:05 PM ED Right now I'm living at my mom's place, which is out in the suburbs a bit. It's like a half hour from here. how Is your paternal grandmother's health Granny's doing good. She's still living on her own. She's slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy. How is your paternal grandfather's health Grandpa Jones passed away when I was really little. do you know Grandpa Jones cause of death (Clarified to How did your grandfather die?.) Well, Grandpa Jones died of colon cancer, and Poppa died of a heart attack. (Clarified to how my grandfather died.) How is your maternal grandmother's health Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. How is your paternal grandfather's health Grandpa Jones passed away when I was really little. how is your maternal grandfather's health Well, Poppa died about five years ago. Do you use any recreational drugs No. What type of work do you do I'm a supervisor at Mid-American Copy & Ship. I've been working there since high school, and I've just kept moving up. That's great to hear that you have been doing well at work (No matching questions found.) HEENT | Completed | Shadow Health 4/4/202 0 11/1 It is great to hear that you have been doing well at work (No matching questions found.) Have you had any fever I appreciate you telling me that. Questio 03/27/20 8:06 PM ED Questio 03/27/20 8:07 PM ED Questio 03/27/20 8:08 PM ED Questio 03/27/20 8:08 PM ED Questio 03/27/20 8:09 PM ED Questio 03/27/20 8:09 PM ED Questio 03/27/20 8:10 PM ED Questio 03/27/20 8:10 PM ED Questio 03/27/20 8:10 PM ED Questio 03/27/20 8:10 PM ED Empathiz 03/27/20 8:11 PM ED Have you had any fever No, I haven't felt feverish at all this week. That's another reason why this seems more like allergies than a cold. Have you had any dizziness No, I can't remember the last time I got dizzy. Have you had any eye discharges Well, they've been watery. Since when do you have blurred vision Yeah, I notice that it gets really blurry if I read for more than an hour or so. Do you have a red eyes Yeah, my eyes have been kinda red. They look the way they do when I'm around a cat, but I haven't been near one. May I examine you Yeah, that's fine. Do you have ear pain (Clarified to Do you have an earache?.) No, my ears don't hurt. (Clarified to if I have an earache.) Are your ears itching No, my ears haven't been itching. Do you feel dizzy I'm not feeling dizzy, no. Do you feel like the room is spinning HEENT | Completed | Shadow Health 4/4/202 0 12/1 I'm not feeling dizzy, no. Have you had any ear surgeries No, I've never had any major problems with my ears. Question 03/27/20 8:11 PM ED Question 03/27/20 8:11 PM ED Questio 03/27/20 8:12 PM ED Questio 03/27/20 8:12 PM ED Questio 03/27/20 8:12 PM ED Questio 03/27/20 8:12 PM ED Questio 03/27/20 8:13 PM ED Questio 03/27/20 8:14 PM ED Questio 03/27/20 8:14 PM ED Questio 03/27/20 8:14 PM ED Questio 03/27/20 8:14 PM ED HEENT | Completed | Shadow Health 4/4/202 0 15/1Open and close your mouth (No matching questions found.) Performed otoscopic examination of left ear Performed otoscopic examination of right ear Performed otoscopic examination of left ear Inspected mouth Inspected mouth: pushed tongue left with tongue blade Inspect mouth: pushed tongue right with tongue blade Inspect mouth: lifted tongue with tongue blade Inspected mouth: depressed tongue with tongue blade Inspected front of neck Inspected right side of neck Inspected back of neck Inspected left side of neck Inspected front of neck Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported Palpated frontal sinuses: No tenderness reported Palpated maxillary sinuses: No tenderness reported Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+ Palpated right carotid artery: No thrill, 2+ Palpated left carotid artery: No thrill, 2+ Palpated jaw: Full range of motion, no popping or clicking Exam Actio 03/27/20 8:19 PM ED Exam Actio 03/27/20 8:19 PM ED Exam Actio 03/27/20 8:20 PM ED Exam Actio 03/27/20 8:20 PM ED Exam Actio 03/27/20 8:20 PM ED Exam Actio 03/27/20 8:21 PM ED Exam Actio 03/27/20 8:21 PM ED Exam Actio 03/27/20 8:21 PM ED Exam Actio 03/27/20 8:23 PM ED Exam Actio 03/27/20 8:23 PM ED Exam Actio 03/27/20 8:23 PM ED Exam Actio 03/27/20 8:23 PM ED Exam Actio 03/27/20 8:23 PM ED Exam Actio 03/27/20 8:24 PM ED Exam Actio 03/27/20 8:24 PM ED Exam Actio 03/27/20 8:24 PM ED Exam Actio 03/27/20 8:25 PM ED HEENT | Completed | Shadow Health 4/4/202 0 16/1 Exam Actio 03/27/20 8:25 PM ED Exam Actio 03/27/20 8:25 PM ED Exam Actio 03/27/20 8:26 PM ED Questio 03/27/20 8:26 PM ED HEENT | Completed | Shadow Health 4/4/202 0 17/1 Follow my finger with just your eyes Palpated lymph nodes of head and neck: Not palpable Palpated supraclavicular lymph nodes: Not palpable Palpated axillary lymph nodes: Not palpable Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported Palpated frontal sinuses: No tenderness reported Palpated maxillary sinuses: No tenderness reported Auscultated breath sounds in anterior right upper lobe Auscultated breath sounds in anterior left upper lobe Auscultated breath sounds in anterior left mid-chest (upper lobe) Auscultated breath sounds in anterior right middle lobe Auscultated breath sounds in anterior right lower lobe Auscultated breath sounds in anterior left lower lobe Auscultated right temporal pulse Auscultated left temporal pulse Auscultated right carotid pulse Auscultated left carotid pulse Tested left pupillary reaction with penlight Tested right pupillary reaction with penlight Exam Actio 03/27/20 8:27 PM ED Exam Actio 03/27/20 8:27 PM ED Exam Actio 03/27/20 8:27 PM ED Exam Actio 03/27/20 8:27 PM ED Exam Actio 03/27/20 8:28 PM ED Exam Actio 03/27/20 8:28 PM ED Exam Actio 03/27/20 8:28 PM ED Exam Actio 03/27/20 8:28 PM ED Exam Actio 03/27/20 8:28 PM ED Exam Actio 03/27/20 8:29 PM ED Exam Actio 03/27/20 8:29 PM ED Exam Actio 03/27/20 8:29 PM ED Exam Actio 03/27/20 8:29 PM ED Exam Actio 03/27/20 8:29 PM ED Exam Actio 03/27/20 8:30 PM ED Exam Actio 03/27/20 8:30 PM ED Exam Actio 03/27/20 8:30 PM ED HEENT | Completed | Shadow Health 4/4/202 0 20/1 Is the volume the same in both ears or louder in one ear Ok. Exam Actio 03/27/20 8:32 PM ED Questio 03/27/20 8:35 PM ED HEENT | Completed | Shadow Health 4/4/202 0 21/1 Same in both ears. Me when you no longer hear the ringing Ok, I will. Now. Tell me when you no longer hear the ringing Ok, I will. Now. F. F. Eight Eight. W. W. Four Four. Nine. Nine. Performed Weber test with tuning fork Exam Actio 03/27/20 8:35 PM ED Questio 03/27/20 8:35 PM ED Questio 03/27/20 8:36 PM ED Questio 03/27/20 8:36 PM ED Questio 03/27/20 8:36 PM ED Questio 03/27/20 8:36 PM ED Performed whisper test in right ear Exam Actio 03/27/20 8:37 PM ED Questio 03/27/20 8:37 PM ED Questio 03/27/20 8:37 PM ED Questio 03/27/20 8:37 PM ED Performed whisper test in left ear Exam Actio 03/27/20 8:37 PM ED HEENT | Completed | Shadow Health 4/4/202 0 22/1 Tested gag reflex with tongue blade Exam Actio 03/27/20 8:37 PM ED Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health® 2012 - 2020 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (https://www.shadowhealth.com/patents)