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
Your avatar 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
Tina Jones Hey.
Your avatar May I know your name, please? Question 05/29/20 6:31 PM EDT
Tina Jones Tina Jones.
Your avatar What brings you to the Clinic today Tina? Question 05/29/20 6:31 PM EDT
Tina Jones My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
Your avatar Am sorry to hear that Empathize 05/29/20 6:32 PM EDT
Tina Jones I appreciate you telling me that. Tina Jones HEENT shadow health assessment transcript
Your avatar How long have you had these symptoms? Question 05/29/20 6:32 PM EDT
Tina Jones My itchy eyes, runny nose, and sore throat all started a week ago. [AUDIO COMING SOON]
Your avatar Have you ever had these symptoms before? Question 05/29/20 6:33 PM EDT
Tina Jones No.
Your avatar How severe is your sore throat? Question 05/29/20 6:36 PM EDT
Tina Jones It’s not… terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won’t go away.
Your avatar Is the sore throat constant? Question 05/29/20 6:36 PM EDT
Tina Jones Yeah, it’s sore pretty much all the time.
Your avatar can you describe the pain? Question 05/29/20 6:38 PM EDT
Tina Jones It’s really sore, and it itches a lot, like in the back.
Your avatar how would you rate the pain on a scale of 0 to 10? Question 05/29/20 6:38 PM EDT
Tina Jones It’s like a 4 out of 10, maybe.
Your avatar Does the pain radiate? Question 05/29/20 6:38 PM EDT
Tina Jones No, it’s just in my throat.
Your avatar What do you think is causing the sore throat? Question 05/29/20 6:39 PM EDT
Tina Jones 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.
Your avatar Does anything make the throat feel better? Question 05/29/20 6:40 PM EDT
Tina Jones All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
Your avatar Does anything make the pain worse? Question 05/29/20 6:41 PM EDT
Tina Jones It’s a little worse in the morning, but that’s really the only pattern I’ve noticed.
Your avatar Do you have any other symptoms associated with the sore throat? (No matching questions found.) Question 05/29/20 6:43 PM EDT
Your avatar do you have any nasal discharge? Question 05/29/20 6:43 PM EDT
Tina Jones Yes, it won’t stop running!
Your avatar
Tina Jones HEENT shadow health assessment transcript
Your avatar Do you take any over-the-counter medications? Question 05/29/20 6:50 PM EDT
Tina Jones I’ve been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often.
Your avatar How often do you get headaches? Question 05/29/20 6:51 PM EDT
Tina Jones 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.
Your avatar How would you rate these headaches? Question 05/29/20 6:51 PM EDT
Tina Jones Not too bad. . . I’d say about 3. Or a 4 if I really push it.
Your avatar What helps your headache? Question 05/29/20 6:51 PM EDT
Tina Jones I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON]
Your avatar Does anything make your headaches worse? Question 05/29/20 6:52 PM EDT
Tina Jones 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.
Your avatar How long have you had these headaches? Question 05/29/20 6:52 PM EDT
Tina Jones I’m not sure — Maybe over the last year or so.
Your avatar Do you take any herbal supplements? Question 05/29/20 6:53 PM EDT
Tina Jones No, I don’t take anything herbal.
Your avatar Do you take any prescription medications? Question 05/29/20 6:53 PM EDT
Tina Jones
Tina Jones HEENT shadow health assessment transcript
Your avatar Do you take vitamins? Question 05/29/20 7:21 PM EDT
Tina Jones No, I don’t take any vitamins.
Your avatar Are your immunizations up to date? Question 05/29/20 7:22 PM EDT
Tina Jones I’m pretty sure I am, yeah.
Your avatar What side effects did you have with metformin? Question 05/29/20 7:23 PM EDT
Tina Jones I felt sick and gassy all the time. It was really uncomfortable.
Your avatar 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
Tina Jones Alright, thanks for letting me know.
Your avatar Are you allergic to medications? Question 05/29/20 7:28 PM EDT
Tina Jones Yeah, I’m allergic to penicillin.
Your avatar Do you have seasonal allergies? Question 05/29/20 7:28 PM EDT
Tina Jones 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.
Your avatar 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
Tina Jones Nope, no food allergies that I know of. (Clarified to if I have food allergies.)
Your avatar Do you smoke cigarettes? Question 05/29/20 7:32 PM EDT
Tina Jones No, I’ve never smoked a cigarette in my life.
Your avatar Do you take alcohol? (No matching questions found.) Question 05/29/20 7:32 PM EDT
Your avatar Do you drink alcohol? Question 05/29/20 7:33 PM EDT
Tina Jones I do sometimes, yeah, when I go out with my friends.
Your avatar 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
Tina Jones 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.)
Your avatar That’s moderate drinking which is ok. Educate 05/29/20 7:34 PM EDT
Tina Jones Thanks for telling me.
Your avatar What type of alcohol do you take? Question 05/29/20 7:34 PM EDT
Tina Jones I usually get rum and diet coke. I don’t know why that matters.
Your avatar Different drinks have different alcohol levels, that’s why I asked. Educate 05/29/20 7:35 PM EDT
Tina Jones OK, I understand.
Your avatar How is your family medical history? Question 05/29/20 7:35 PM EDT
Tina Jones My mom has some issues, and I think some of my grandparents did, too.
Your avatar What health issues does your mother have? Question 05/29/20 7:35 PM EDT
Tina Jones Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
Your avatar What medical issues does your father have? (Clarified to Tell me about your dad’s health?.) Question 05/29/20 7:36 PM EDT
Tina Jones He passed last year. (Clarified to what health issues my dad has.)
Your avatar Am sorry to hear that Empathize 05/29/20 7:36 PM EDT
Tina Jones Thanks for understanding.
Your avatar did your father have any medical conditions? Question 05/29/20 7:37 PM EDT
Tina Jones He had high blood pressure and cholesterol, and diabetes too…the same kind as me.
Your avatar What health issues does your maternal grandmother have? Question 05/29/20 7:37 PM EDT
Tina Jones Nana had high blood pressure and cholesterol, I think. Tina Jones HEENT shadow health assessment transcript
Your avatar What issues does your maternal grandfather have? Question 05/29/20 7:38 PM EDT
Tina Jones Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
Your avatar What health issues does your paternal grandmother have? Question 05/29/20 7:38 PM EDT
Tina Jones 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.
Your avatar What health issues does your paternal grandfather have? Question 05/29/20 7:39 PM EDT
Tina Jones 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.
Your avatar how did you cope with your father’s death? Question 05/29/20 7:39 PM EDT
Tina Jones 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.
Your avatar Seems you have a strong support system which is great. Empathize 05/29/20 7:40 PM EDT
Tina Jones Thanks.
Your avatar What health conditions does your sister have? Question 05/29/20 7:41 PM EDT
Tina Jones She’s pretty healthy. She has asthma too, but she almost never has attacks.
Your avatar what health conditions does your brother have? Question 05/29/20 7:41 PM EDT
Tina Jones None that I know of. He’s got some extra weight on him, I guess.
Your avatar Anyone with an obesity problem in your family? Question 05/29/20 7:45 PM EDT
Tina Jones 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.
Your avatar Anyone with an alcoholism problem in the family? Question 05/29/20 7:46 PM EDT
Tina Jones One person in the family, my dad’s brother, has an alcohol problem, but we never see him.
Your avatar What work do you do? Question 05/29/20 7:47 PM EDT
Tina Jones I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up.
Your avatar Am happy to hear that your job is fine and you are doing well Empathize 05/29/20 7:47 PM EDT
Tina Jones Thanks for understanding.
Your avatar What is your highest level of education? Question 05/29/20 7:48 PM EDT
Tina Jones Well, I’m finishing up my Bachelor’s degree right now.
Your avatar What is your Major? Question 05/29/20 7:48 PM EDT
Tina Jones I’m going to get my bachelor’s in accounting.
Your avatar
Tina Jones HEENT shadow health assessment transcript.
Tina Jones 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.
Your avatar Am sure when you get less busy, you will travel more Empathize 05/29/20 7:52 PM EDT
Tina Jones I appreciate you saying that.
Your avatar Have you been wheezing? Question 05/29/20 7:52 PM EDT
Tina Jones No, I haven’t been wheezing this week.
Your avatar Please let me examine you now. (No matching questions found.) Question 05/29/20 7:53 PM EDT
Your avatar Please let me examine you now. Educate 05/29/20 7:53 PM EDT
Tina Jones Sure, I think I understand what you mean.
Your avatar Inspected general face Exam Action 05/29/20 7:57 PM EDT
Your avatar Inspected forehead and scalp Exam Action 05/29/20 7:58 PM EDT
Your avatar Inspected nose and mouth Exam Action 05/29/20 7:58 PM EDT
Your avatar Inspected left side of the face Exam Action 05/29/20 7:58 PM EDT
Your avatar Inspected back of the head Exam Action 05/29/20 7:58 PM EDT
Your avatar Inspected right side of the face Exam Action 05/29/20 7:58 PM EDT
Your avatar Inspected general face Exam Action 05/29/20 7:58 PM EDT
Your avatar Inspected right side of the face Exam Action 05/29/20 7:58 PM EDT
Your avatar Inspected general face Exam Action 05/29/20 7:58 PM EDT
Your avatar Inspected nose and mouth Exam Action 05/29/20 7:58 PM EDT
Your avatar Inspected forehead and scalp Exam Action 05/29/20 7:58 PM EDT
Your avatar Inspected nose and mouth Exam Action 05/29/20 7:58 PM EDT
Your avatar Inspected right orbital area and sclera Exam Action 05/29/20 7:59 PM EDT
Your avatar Inspected lower conjunctiva Exam Action 05/29/20 7:59 PM EDT
Your avatar Inspected upper conjunctiva Exam Action 05/29/20 8:00 PM EDT
Your avatar Inspected upper conjunctiva Exam Action 05/29/20 8:00 PM EDT
Your avatar Inspected left orbital area and sclera Exam Action 05/29/20 8:00 PM EDT
Your avatar Performed otoscopic examination of right naris Exam Action 05/29/20 8:00 PM EDT
Your avatar Performed otoscopic examination of left naris Exam Action 05/29/20 8:01 PM EDT
Your avatar Performed otoscopic examination of the right ear Exam Action 05/29/20 8:02 PM EDT
Your avatar Performed otoscopic examination of left ear Exam Action 05/29/20 8:02 PM EDT
Your avatar Inspected mouth Exam Action 05/29/20 8:03 PM EDT
Your avatar Inspected mouth: pushed tongue left with tongue blade Exam Action 05/29/20 8:04 PM EDT
Your avatar Inspect mouth: pushed tongue right with tongue blade Exam Action 05/29/20 8:04 PM EDT
Your avatar Inspect mouth: lifted tongue with tongue blade Exam Action 05/29/20 8:04 PM EDT
Your avatar Inspected mouth: depressed tongue with tongue blade Exam Action 05/29/20 8:04 PM EDT
Your avatar Inspected front of neck Exam Action 05/29/20 8:06 PM EDT
Your avatar Inspected left side of neck Exam Action 05/29/20 8:06 PM EDT
Your avatar Inspected back of neck Exam Action 05/29/20 8:06 PM EDT
Your avatar Inspected right side of neck Tina Jones HEENT shadow health assessment transcript. Exam Action 05/29/20 8:06 PM EDT
Your avatar Inspected back of neck Exam Action 05/29/20 8:06 PM EDT
Your avatar Inspected right side of neck Exam Action 05/29/20 8:07 PM EDT
Your avatar Inspected front of neck Exam Action 05/29/20 8:07 PM EDT
Your avatar Inspected right side of neck Exam Action 05/29/20 8:07 PM EDT
Your avatar Inspected front of neck Exam Action 05/29/20 8:07 PM EDT
Your avatar Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported Exam Action 05/29/20 8:07 PM EDT
Your avatar Palpated maxillary sinuses: No tenderness reported Exam Action 05/29/20 8:08 PM EDT
Your avatar Palpated frontal sinuses: No tenderness reported Exam Action 05/29/20 8:08 PM EDT
Your avatar Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+ Exam Action 05/29/20 8:08 PM EDT
Your avatar Palpated right carotid artery: No thrill, 2+ Exam Action 05/29/20 8:10 PM EDT
Your avatar Palpated left carotid artery: No thrill, 2+ Exam Action 05/29/20 8:10 PM EDT
Your avatar Palpated jaw: Full range of motion, no popping or clicking Exam Action 05/29/20 8:11 PM EDT
Your avatar Palpated axillary lymph nodes: Not palpable Exam Action 05/29/20 8:11 PM EDT
Your avatar Palpated supraclavicular lymph nodes: Not palpable Exam Action 05/29/20 8:12 PM EDT
Your avatar Palpated lymph nodes of head and neck: Not palpable Exam Action 05/29/20 8:12 PM EDT
Your avatar Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported Exam Action 05/29/20 8:12 PM EDT
Your avatar Auscultated breath sounds in anterior right lower lobe Exam Action 05/29/20 8:13 PM EDT
Your avatar Auscultated breath sounds in anterior right middle lobe Exam Action 05/29/20 8:13 PM EDT
Your avatar Auscultated breath sounds in anterior right upper lobe Exam Action 05/29/20 8:13 PM EDT
Your avatar Auscultated breath sounds in anterior left upper lobe Exam Action 05/29/20 8:13 PM EDT
Your avatar Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 05/29/20 8:13 PM EDT
Your avatar Auscultated breath sounds in anterior left lower lobe Exam Action 05/29/20 8:13 PM EDT
Your avatar Auscultated breath sounds in posterior left upper lobe Exam Action 05/29/20 8:13 PM EDT
Your avatar Auscultated breath sounds in posterior left mid-back (lower lobe) Exam Action 05/29/20 8:13 PM EDT
Your avatar Auscultated breath sounds in posterior left lower lobe Exam Action 05/29/20 8:13 PM EDT
Your avatar Auscultated breath sounds in posterior left lower lobe on side Exam Action 05/29/20 8:13 PM EDT
Your avatar Auscultated breath sounds in posterior left lower lobe near spine Exam Action 05/29/20 8:13 PM EDT
Your avatar Auscultated breath sounds in posterior right lower lobe near spine Exam Action 05/29/20 8:14 PM EDT
Your avatar Auscultated breath sounds in posterior right lower lobe on side Exam Action 05/29/20 8:14 PM EDT
Your avatar Auscultated breath sounds in posterior right lower lobe Exam Action 05/29/20 8:14 PM EDT
Your avatar Auscultated breath sounds in posterior right mid-back (lower lobe) Exam Action 05/29/20 8:14 PM EDT
Your avatar Auscultated breath sounds in posterior right upper lobe Exam Action 05/29/20 8:14 PM EDT
Your avatar Auscultated right temporal pulse Exam Action 05/29/20 8:14 PM EDT
Your avatar Auscultated left temporal pulse Exam Action 05/29/20 8:14 PM EDT
Your avatar Auscultated right carotid pulse Exam Action 05/29/20 8:15 PM EDT
Your avatar Auscultated left carotid pulse Exam Action 05/29/20 8:15 PM EDT
Your avatar Tested left pupillary reaction with penlight Exam Action 05/29/20 8:16 PM EDT
Your avatar Tested right pupillary reaction with penlight Exam Action 05/29/20 8:16 PM EDT
Your avatar Follow my finger with just your eyes Question 05/29/20 8:17 PM EDT
Tina Jones Ok.
Your avatar Tested EOM to the upper right Exam Action 05/29/20 8:17 PM EDT
Your avatar Tested EOM to the lower right Exam Action 05/29/20 8:17 PM EDT
Your avatar Tested EOM to the lower center Exam Action 05/29/20 8:17 PM EDT
Your avatar Tested convergence to the center Exam Action 05/29/20 8:17 PM EDT
Your avatar Tested EOM to the upper center Exam Action 05/29/20 8:17 PM EDT
Your avatar Tested EOM to the upper left Exam Action 05/29/20 8:17 PM EDT
Your avatar Tested EOM to the lower left Exam Action 05/29/20 8:17 PM EDT
Your avatar Tell me when you can no loner see Question 05/29/20 8:18 PM EDT
Tina Jones Ok, I will.
Your avatar Tested peripheral vision Exam Action 05/29/20 8:18 PM EDT
Tina Jones Now.
Your avatar Examined fundus of right eye with ophthalmoscope Exam Action 05/29/20 8:20 PM EDT
Your avatar Examined fundus of left eye with ophthalmoscope Exam Action 05/29/20 8:21 PM EDT
Tina Jones F P
Your avatar Is the volume the same in both ears or louder in one ear Question 05/29/20 8:24 PM EDT
Tina Jones Ok.
Tina Jones Same in both ears.
Your avatar Performed Weber test with tuning fork Exam Action 05/29/20 8:25 PM EDT
Your avatar Tell me when you no longer hear the ringing Question 05/29/20 8:25 PM EDT
Tina Jones Ok, I will.
Tina Jones Now.
Your avatar F. Question 05/29/20 8:26 PM EDT
Tina Jones F.
Your avatar Eight Question 05/29/20 8:26 PM EDT
Tina Jones Eight.
Your avatar W. Question 05/29/20 8:26 PM EDT
Tina Jones W.
Your avatar Performed whisper test in right ear Exam Action 05/29/20 8:26 PM EDT
Your avatar Four Question 05/29/20 8:26 PM EDT
Tina Jones Four.
Your avatar R. Question 05/29/20 8:26 PM EDT
Tina Jones R.
Your avatar Nine. Question 05/29/20 8:26 PM EDT
Tina Jones Nine.
Your avatar Performed whisper test in left ear Exam Action 05/29/20 8:27 PM EDT
Your avatar Tested gag reflex with tongue blade Exam Action 05/29/20 8:27 PM EDT
Tina Jones HEENT shadow health assessment transcript
HEENT Results Turned In
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Frequently Asked Questions (FAQs)

1. How do you assess HEENT?

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
Tina Jones HEENT Shadow Health Assessment Transcript

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