NURSING 301 Shadow Health HEENT Transcript NEWEST, Exams of Nursing

Download NURSING 301 Shadow Health HEENT Transcript NEWEST and more Exams Nursing in PDF only on Docsity! NURSING 301 Shadow Health HEENT Transcript NEWEST HEENT Results | Turned InHolistic Health Assessment - NUR 301 Return to Assignment Your Results Lab Pass • Overview • Transcript • Subjective Data Collection • Objective Data Collection • Documentation Transcript All Lines (132)Interview Questions (57)Statements (4)Exam Actions (71) Hello! Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. What is the situation? Question 11/01/20 5:05 PM EST Question 11/01/20 5:08 PM EST In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment on average takes between 60 and 75 minutes. You can pause and resume the assignment at any time; your work is always saved automatically. How does this assignment prepare me for the real world? In this assessment, you will become familiarized with the structure and content of HEENT exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient's risk of disease, infection, injury, and complications º and obtain and assess objective data. Question 11/01/20 5:14 PM EST In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What physical exam findings would you look for in a patient with allergies? A patient with allergies might present with symptoms such as swelling in the throat and drainage. Time to begin. Hello, my name is Jennifer and I am the nursing student that will interview you today. Statement 11/01/20 5:18 PM EST Greet 11/01/20 5:18 PM EST Hey. Can you tell me your name and date of birth? My name's Tina Jones, and my birthday's February 17th. How old are you? Question 11/01/20 5:20 PM EST Question 11/01/20 5:20 PM EST Do you have any problems with your head? Just like in general? I get headaches sometimes. How often do you get headaches? Maybe every week? I usually do a lot of my school work at once, so I'll study for like, 5 or 6 hours. I usually end up with a headache by the end of the night. How long do your headaches last? Question 11/01/20 5:52 PM EST Question 11/01/20 5:52 PM EST Question 11/01/20 5:53 PM EST A few hours, I guess. Where are your headaches located? It's kind of behind my forehead. Can you rate your headache pain on a scale of 0-10? Question 11/01/20 5:53 PM EST Question 11/01/20 5:54 PM EST Not too bad. . . I'd say about 2. Or a 3 if I really push it. Do you take any medicATION FOR YOUR HEADACHES? Yeah. Usually I'll take a Tylenol and go to bed, and that'll get rid of it. dO YOU HAVE ANY TROUBLE WITH YOUR VISION? Question 11/01/20 5:54 PM EST Question 11/01/20 5:55 PM EST Never. I know that when I was a kid, the school nurse did those little vision checks every year, but I haven't gotten an eye exam since then. (Clarified to if I have seen a doctor about my vision.) Do you have any other problems with your eyes? No. Is there anything that triggers your vision to get blurry? Question 11/01/20 5:58 PM EST Question 11/01/20 5:58 PM EST It definitely gets blurry or kind of fuzzy when I read. But that's the only time I notice that. Are there any triggers for your eye symptoms? Just when I'm around a cat, which isn't very often. Sometimes dust will do it, too. [AUDIO COMING SOON] Do you get any treatment for your eye symptoms? (Clarified to What treatment do you use for your eye symptoms?.) Question 11/01/20 5:58 PM EST Question 11/01/20 5:59 PM EST If I'm having an allergic reaction, I just rinse my eyes out in the shower. [AUDIO COMING SOON] (Clarified to what treatment I use for my eye symptoms.) Do you have any nasal problems? Sometimes my nose gets runny. It's fine right now, though. [AUDIO COMING SOON] Do you have any sinus problems? Question 11/01/20 6:00 PM EST Question 11/01/20 6:02 PM EST Just a few. I'm not a big drinker. Do you use tobacco products? No. I think it's gross. Do you have any ear problems? Question 11/01/20 6:04 PM EST Question 11/01/20 6:05 PM EST No, my ears are fine right now. Do you have any trouble hearing? No. Do you have any moth problems? (No matching questions found.) Do you have any mouth problems? Question 11/01/20 6:05 PM EST Question 11/01/20 6:05 PM EST Question 11/01/20 6:05 PM EST No. Do you have any dental problems? No, I've got good teeth. They don't give me any problems. Do you have any problems with your throat? Question 11/01/20 6:07 PM EST Question 11/01/20 6:08 PM EST No. Do you have a family history of ear problems? No. Do you have a family history of nasal problems? Question 11/01/20 6:10 PM EST Question 11/01/20 6:10 PM EST Yeah, my sister gets hay fever, so every spring she sneezes and her nose runs. She has to take something over-the-counter for it. Do you have a family history of mouth problems? No, not really. Do you have a family history of throat problems? Question 11/01/20 6:11 PM EST Question 11/01/20 6:11 PM EST No. Do you have a family history of gland problems? I don't think so. I am now going to examine you. Question 11/01/20 6:11 PM EST Educate 11/01/20 6:12 PM EST 6:15 PM EST Performed otoscopic examination of left naris Performed otoscopic examination of right ear Performed otoscopic examination of left ear Inspected mouth Inspected front of neck Inspected right side of neck Inspected front of neck Inspected neck 6:15 PM EST Exam Action 11/01/20 6:13 PM EST Exam Action 11/01/20 6:14 PM EST Exam Action 11/01/20 6:14 PM EST Exam Action 11/01/20 6:14 PM EST Exam Action 11/01/20 6:14 PM EST Exam Action 11/01/20 6:15 PM EST Exam Action 11/01/20 6:15 PM EST Exam Action 11/01/20 6:19 PM EST 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 right carotid artery: No thrill, 2+ Palpated left carotid artery: No thrill, 2+ Palpated jaw: Full range of motion, no popping or clicking Palpated lymph nodes of head and neck: Not palpable Palpated supraclavicular lymph nodes: Not palpable Exam Action 11/01/20 6:16 PM EST Exam Action 11/01/20 6:16 PM EST Exam Action 11/01/20 6:16 PM EST Exam Action 11/01/20 6:17 PM EST Exam Action 11/01/20 6:17 PM EST Exam Action 11/01/20 6:18 PM EST Exam Action 11/01/20 6:19 PM EST Exam Action 11/01/20 Tested convergence to the center Tested EOM to the upper left Tested EOM to the lower left Tested EOM to the lower center Tell me when you can no longer see my fingers. Ok, I will. Exam Action 11/01/20 6:31 PM EST Exam Action 11/01/20 6:31 PM EST Exam Action 11/01/20 6:31 PM EST Exam Action 11/01/20 6:31 PM EST Question 11/01/20 6:31 PM EST Tested peripheral vision Now. Examined fundus of right eye Examined fundus of left eye L P E D Exam Action 11/01/20 6:31 PM EST Exam Action 11/01/20 6:32 PM EST Exam Action 11/01/20 6:32 PM EST L P E D P E C F D Tested visual acuity of right eye (left eye covered) Exam Action 11/01/20 6:39 PM EST Tested visual acuity of left eye (right eye covered) D E F P O T E C Tested visual acuity of left eye (right eye covered) That's... I can't really tell. Exam Action 11/01/20 6:41 PM EST Exam Action 11/01/20 6:41 PM EST Um, that one's kind of blurry. E D E O X F P E C F D Tested visual acuity of right eye (left eye covered) Four Four. R. R. Exam Action 11/01/20 6:42 PM EST Question 11/01/20 6:43 PM EST Question 11/01/20 6:43 PM EST Inspected general face Performed otoscopic examination of right naris Performed otoscopic examination of left naris Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported Do you have any tenderness on your scalp? No, I keep my scalp healthy. Exam Action 11/01/20 6:46 PM EST Exam Action 11/01/20 6:48 PM EST Exam Action 11/01/20 6:48 PM EST Exam Action 11/01/20 7:21 PM EST Question 11/01/20 7:21 PM EST Palpated frontal sinuses: No tenderness reported Palpated maxillary sinuses: No tenderness reported Palpated right carotid artery: No thrill, 2+ Palpated left carotid artery: No thrill, 2+ Palpated jaw: Full range of motion, no popping or clicking Palpated lymph nodes of head and neck: Not palpable Palpated supraclavicular lymph nodes: Not palpable Palpated axillary lymph nodes: Not palpable Exam Action 11/01/20 7:21 PM EST Exam Action 11/01/20 7:21 PM EST Exam Action 11/01/20 7:22 PM EST Exam Action 11/01/20 7:22 PM EST Exam Action 11/01/20 7:22 PM EST Exam Action 11/01/20 7:23 PM EST Exam Action 11/01/20 7:23 PM EST Exam Action 11/01/20 7:23 PM EST Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported Auscultated right carotid artery Auscultated left carotid artery What brings you in today? Well, I came in last night for my foot. It just wasn't healing right, and it really hurt. I am sorry you are having pain. Exam Action 11/01/20 7:24 PM EST Exam Action 11/01/20 7:25 PM EST Exam Action 11/01/20 7:25 PM EST Question 11/01/20 7:48 PM EST Empathize 11/01/20 7:49 PM EST