Tina Jones HEENT shadow health assessment transcript
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Tina Jones HEENT shadow health assessment transcript
Transcript
Started: May 17, 2020 | Total Time:96 min
Hello. My name is xxx. I will be interviewing you today and then conducting a physical exam.
Greet
05/29/20 6:31 PM EDT
Hey.
May I know your name, please?
Question
05/29/20 6:31 PM EDT
Tina Jones.
What brings you to the Clinic today Tina?
Question
05/29/20 6:31 PM EDT
My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
My itchy eyes, runny nose, and sore throat all started a week ago. [AUDIO COMING SOON]
Have you ever had these symptoms before?
Question
05/29/20 6:33 PM EDT
No.
How severe is your sore throat?
Question
05/29/20 6:36 PM EDT
It’s not… terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won’t go away.
Is the sore throat constant?
Question
05/29/20 6:36 PM EDT
Yeah, it’s sore pretty much all the time.
can you describe the pain?
Question
05/29/20 6:38 PM EDT
It’s really sore, and it itches a lot, like in the back.
how would you rate the pain on a scale of 0 to 10?
Question
05/29/20 6:38 PM EDT
It’s like a 4 out of 10, maybe.
Does the pain radiate?
Question
05/29/20 6:38 PM EDT
No, it’s just in my throat.
What do you think is causing the sore throat?
Question
05/29/20 6:39 PM EDT
At first, I thought I was getting sick, or a cold or something, but now it doesn’t seem like that. My throat hasn’t gotten worse, but it’s not going away either.
Does anything make the throat feel better?
Question
05/29/20 6:40 PM EDT
All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
Does anything make the pain worse?
Question
05/29/20 6:41 PM EDT
It’s a little worse in the morning, but that’s really the only pattern I’ve noticed.
Do you have any other symptoms associated with the sore throat? (No matching questions found.)
I’ve been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often.
How often do you get headaches?
Question
05/29/20 6:51 PM EDT
Maybe once a 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 would you rate these headaches?
Question
05/29/20 6:51 PM EDT
Not too bad. . . I’d say about 3. Or a 4 if I really push it.
What helps your headache?
Question
05/29/20 6:51 PM EDT
I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON]
Does anything make your headaches worse?
Question
05/29/20 6:52 PM EDT
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.
I felt sick and gassy all the time. It was really uncomfortable.
When you get side effects that you cannot tolerate, you should speak to your doctor for alternatives and also confirm if they react with other medications
Educate
05/29/20 7:25 PM EDT
Alright, thanks for letting me know.
Are you allergic to medications?
Question
05/29/20 7:28 PM EDT
Yeah, I’m allergic to penicillin.
Do you have seasonal allergies?
Question
05/29/20 7:28 PM EDT
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.
Do you have food allergies? Are you allergic to latex? (Clarified to Do you have food allergies?.)
Question
05/29/20 7:29 PM EDT
Nope, no food allergies that I know of. (Clarified to if I have food allergies.)
Do you smoke cigarettes?
Question
05/29/20 7:32 PM EDT
No, I’ve never smoked a cigarette in my life.
Do you take alcohol? (No matching questions found.)
Question
05/29/20 7:32 PM EDT
Do you drink alcohol?
Question
05/29/20 7:33 PM EDT
I do sometimes, yeah, when I go out with my friends.
How many drinks do you take when you go out? (Clarified to How many drinks do you have when you go out at night?.)
Question
05/29/20 7:33 PM EDT
Like, two or three drinks. If I have more than two or three drinks, I feel like hell the next day, so I stop at three. (Clarified to how many alcoholic drinks I have when I go out.)
That’s moderate drinking which is ok.
Educate
05/29/20 7:34 PM EDT
Thanks for telling me.
What type of alcohol do you take?
Question
05/29/20 7:34 PM EDT
I usually get rum and diet coke. I don’t know why that matters.
Different drinks have different alcohol levels, that’s why I asked.
Educate
05/29/20 7:35 PM EDT
OK, I understand.
How is your family medical history?
Question
05/29/20 7:35 PM EDT
My mom has some issues, and I think some of my grandparents did, too.
What health issues does your mother have?
Question
05/29/20 7:35 PM EDT
Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
What medical issues does your father have? (Clarified to Tell me about your dad’s health?.)
Question
05/29/20 7:36 PM EDT
He passed last year. (Clarified to what health issues my dad has.)
Am sorry to hear that
Empathize
05/29/20 7:36 PM EDT
Thanks for understanding.
did your father have any medical conditions?
Question
05/29/20 7:37 PM EDT
He had high blood pressure and cholesterol, and diabetes too…the same kind as me.
What health issues does your maternal grandmother have?
Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
What health issues does your paternal grandmother have?
Question
05/29/20 7:38 PM EDT
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.
What health issues does your paternal grandfather have?
Question
05/29/20 7:39 PM EDT
Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and…I’m pretty sure he had diabetes.
how did you cope with your father’s death?
Question
05/29/20 7:39 PM EDT
Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, and she was kinda depressed. So I guess at first I just focused on getting things done–groceries, laundry, insurance papers, and stuff. Knowing that Mom needed me kinda helped me get through day by day. There was a month when it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out, gave us rides to church, and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months.
Seems you have a strong support system which is great.
Empathize
05/29/20 7:40 PM EDT
Thanks.
What health conditions does your sister have?
Question
05/29/20 7:41 PM EDT
She’s pretty healthy. She has asthma too, but she almost never has attacks.
what health conditions does your brother have?
Question
05/29/20 7:41 PM EDT
None that I know of. He’s got some extra weight on him, I guess.
Anyone with an obesity problem in your family?
Question
05/29/20 7:45 PM EDT
No, I don’t think so. My brother and my dad are kind of big, but I wouldn’t say they were obese or anything.
Anyone with an alcoholism problem in the family?
Question
05/29/20 7:46 PM EDT
One person in the family, my dad’s brother, has an alcohol problem, but we never see him.
What work do you do?
Question
05/29/20 7:47 PM EDT
I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up.
Am happy to hear that your job is fine and you are doing well
Empathize
05/29/20 7:47 PM EDT
Thanks for understanding.
What is your highest level of education?
Question
05/29/20 7:48 PM EDT
Well, I’m finishing up my Bachelor’s degree right now.
I really haven’t traveled that much…I’ve always wanted to go to France but I’ve never even been out of the country. I’m always busy with work or school anyway though. We used to go on some family vacations when I was younger, but they were usually just to see some family in other states.
Am sure when you get less busy, you will travel more
Empathize
05/29/20 7:52 PM EDT
I appreciate you saying that.
Have you been wheezing?
Question
05/29/20 7:52 PM EDT
No, I haven’t been wheezing this week.
Please let me examine you now. (No matching questions found.)
Question
05/29/20 7:53 PM EDT
Please let me examine you now.
Educate
05/29/20 7:53 PM EDT
Sure, I think I understand what you mean.
Inspected general face
Exam Action
05/29/20 7:57 PM EDT
Inspected forehead and scalp
Exam Action
05/29/20 7:58 PM EDT
Inspected nose and mouth
Exam Action
05/29/20 7:58 PM EDT
Inspected left side of the face
Exam Action
05/29/20 7:58 PM EDT
Inspected back of the head
Exam Action
05/29/20 7:58 PM EDT
Inspected right side of the face
Exam Action
05/29/20 7:58 PM EDT
Inspected general face
Exam Action
05/29/20 7:58 PM EDT
Inspected right side of the face
Exam Action
05/29/20 7:58 PM EDT
Inspected general face
Exam Action
05/29/20 7:58 PM EDT
Inspected nose and mouth
Exam Action
05/29/20 7:58 PM EDT
Inspected forehead and scalp
Exam Action
05/29/20 7:58 PM EDT
Inspected nose and mouth
Exam Action
05/29/20 7:58 PM EDT
Inspected right orbital area and sclera
Exam Action
05/29/20 7:59 PM EDT
Inspected lower conjunctiva
Exam Action
05/29/20 7:59 PM EDT
Inspected upper conjunctiva
Exam Action
05/29/20 8:00 PM EDT
Inspected upper conjunctiva
Exam Action
05/29/20 8:00 PM EDT
Inspected left orbital area and sclera
Exam Action
05/29/20 8:00 PM EDT
Performed otoscopic examination of right naris
Exam Action
05/29/20 8:00 PM EDT
Performed otoscopic examination of left naris
Exam Action
05/29/20 8:01 PM EDT
Performed otoscopic examination of the right ear
Exam Action
05/29/20 8:02 PM EDT
Performed otoscopic examination of left ear
Exam Action
05/29/20 8:02 PM EDT
Inspected mouth
Exam Action
05/29/20 8:03 PM EDT
Inspected mouth: pushed tongue left with tongue blade
Exam Action
05/29/20 8:04 PM EDT
Inspect mouth: pushed tongue right with tongue blade
Exam Action
05/29/20 8:04 PM EDT
Inspect mouth: lifted tongue with tongue blade
Exam Action
05/29/20 8:04 PM EDT
Inspected mouth: depressed tongue with tongue blade
Examine the head and face for external abnormalities like erythema, which indicates infection, or bruising and deformity, which indicates trauma. The HEENT exam also includes an otoscope examination of the ear canals and tympanic membrane, as well as a pharyngeal examination.
2. What are the 2 physical assessment skills used in HEENT assessment?
Inspection, Palpation, Percussion, Auscultation.
3. What is included in the HEENT exam?
Head, Eyes, Ears, Nose, and Throat (HEENT)
Tina Jones HEENT Shadow Health Assessment Transcript
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