Shadow Health HEENT Focused Exam Transcript

Shadow Health HEENT Focused Exam Transcript

Shadow Health HEENT Focused Exam Transcript

Transcript

Hello Ms. Jones. My name is Alice and I am a nurse practitioner student. I will be doing your history and exam today. Greet
01/25/19 3:36 AM CST
Hey.
What brings you in today Question
01/25/19 3:36 AM CST
My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
I’m sorry these symptoms are causing you distress Empathize
01/25/19 3:37 AM CST
Thanks for saying that.
Have you been experiencing any other symptoms Question
01/25/19 3:37 AM CST
Let’s see… I have a lot going on so here’s the laundry list: sore and itchy throat, runny nose, itchy eyes.
How long have these symptoms been going on Question
01/25/19 3:38 AM CST
Like a week ago, everything started. Sore, itchy throat, runny nose.
When did your eyes start itching Question
01/25/19 3:39 AM CST
They’ve been itchy all week.
Tell me more about your throat pain Question
01/25/19 3:39 AM CST
It’s really sore, and it itches a lot, like in the back.
And the pain constant Question
01/25/19 3:39 AM CST
Yeah, it’s sore pretty much all the time.
When does your sore throat feel the worst Question
01/25/19 3:40 AM CST
It’s a little worse in the morning, but that’s really the only pattern I’ve noticed.
A scale of 0 to 10 how bad is your throat pain Question
01/25/19 3:40 AM CST
It’s like a 4 out of 10, maybe.
I’m sorry you are experiencing pain Empathize
01/25/19 3:40 AM CST
Thanks.
Does it hurt when you try to swallow food Question
01/25/19 3:41 AM CST
Yes, it hurts my throat to swallow.
How often does your nose run Question
01/25/19 3:41 AM CST
It runs all day.
Can you tell me more about your nasal symptoms (No matching questions found.) Question
01/25/19 3:42 AM CST
Can you tell me more about your nose problems Question
01/25/19 3:42 AM CST
It won’t stop running!
What is your nose discharge look like Question
01/25/19 3:43 AM CST
It’s just clear.
Does your nose itch Question
01/25/19 3:43 AM CST
No, my nose isn’t really itchy, but my throat is.
Are you in any other pain besides your throat Question
01/25/19 3:43 AM CST
No, my joints are fine.
Do you feel any sinus pain Question
01/25/19 3:43 AM CST
No, I don’t have any sinus pain. That’s never an issue for me.
Do you feel any sinus pressure Question
01/25/19 3:44 AM CST
No, I don’t have any sinus pressure or pain or anything.
Have you been sneezing Question
01/25/19 3:44 AM CST
No, I haven’t been sneezing.
Can you describe your nasal discharge for me Question
01/25/19 3:44 AM CST
It’s just clear.
Is your nasal mucus thick (Clarified to what consistency is your nasal discharge.) Question
01/25/19 3:45 AM CST
It’s, like, just drips. It’s watery. (Clarified to what consistency my nasal discharge is.)
Is your discharge thin from your nose Question
01/25/19 3:45 AM CST
I’ve never noticed anything like that.
Can you tell me more about your nasal discharge (No matching questions found.) Question
01/25/19 3:46 AM CST
is your mucus thick Question
01/25/19 3:46 AM CST
No, it’s like, thin and dripping.
Does your mucus have any pus in it Question
01/25/19 3:47 AM CST
No, it’s clear.
Tell me more about your eye trouble (No matching questions found.) Question
01/25/19 3:47 AM CST
Tell me about your eye trouble Question
01/25/19 3:47 AM CST
They’re itchy around the rims, mostly, and the more I rub them, the itchier they get. It’s been pretty much constantly like this the whole time.
Do your eyes get red whenever you rub them constantly (Clarified to Do you have eye redness?.) Question
01/25/19 3:49 AM CST
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. (Clarified to if my eyes get red.)
Have you experienced any respiratory issues (Clarified to Do you have respiratory problems? .) Question
01/25/19 3:50 AM CST
Yeah, I have asthma. (Clarified to if I have respiratory problems.)
Have you any changes in your breathing Question
01/25/19 3:50 AM CST
No, my breathing has been fine.
Have you had a cough recently Question
01/25/19 3:50 AM CST
No, I haven’t been coughing. Shadow Health HEENT Focused Exam Transcript
My chest feel tight Question
01/25/19 3:51 AM CST
No, my chest is fine.
Have you been wheezing Question
01/25/19 3:51 AM CST
No, I haven’t been wheezing this week.
Has your asthma been worse lately Question
01/25/19 3:51 AM CST
My breathing’s fine. I haven’t had any asthma problems come up.
Have you been recently exposed to any allergens Question
01/25/19 3:51 AM CST
Not lately.
Do you have any allergies Question
01/25/19 3:52 AM CST
Yeah. I’m allergic to cats. And dust, too.
Have you been around dust lately Question
01/25/19 3:52 AM CST
Not lately.
Have you been exposed to cats recently Question
01/25/19 3:52 AM CST
I was around cats like, a month ago at my cousin’s house. I was wheezing a little bit then.
Have you been exposed to mold that you know of recently (Clarified to have you been around mold.) Question
01/25/19 3:52 AM CST
No. (Clarified to if I have been around mold.)
Are you allergic to anything at work Question
01/25/19 3:53 AM CST
No, I don’t notice any symptoms getting worse at work.
How often do you change your bedding at home Question
01/25/19 3:53 AM CST
Every week.
Thats very goo. Changing your bedding often helps keep dust mites and other allergens off of your bedding Educate
01/25/19 3:54 AM CST
That makes sense.
Do you know what’s causing your symptoms Question
01/25/19 3:54 AM CST
I don’t know what’s causing all this. It seemed like a cold at first, but now I’m thinking it could be allergies? I haven’t been around cats or dust, but this just seems like an allergy thing.
Do you think you have a cold Question
01/25/19 3:54 AM CST
Not exactly… At first I thought this was a cold, but it’s just sticking around. I’m not getting better or worse, so I’m starting to think it’s allergies or something.
Do you think you’re having allergic reaction to anything Question
01/25/19 3:55 AM CST
Well, at first I thought this was a cold, but it’s just sticking around. I’m not getting better or worse, so I’m starting to think it’s allergies or something.
Have you smoked cigarettes recently Question
01/25/19 3:55 AM CST
No, I’ve never smoked a cigarette in my life.
I’ve been exposed to secondhand smoke recently Question
01/25/19 3:56 AM CST
I don’t think I ever am. Sometimes kids smoke outside on campus, but that’s about the only time I’m ever near cigarette smoke.
Do taking medication (Clarified to do you take medications.) Question
01/25/19 3:56 AM CST
I’ve been using throat drops, like lozenges, for my sore throat. Other than that, I just have my inhaler. (Clarified to if I take medications.)
What do you use your inhaler for Question
01/25/19 3:56 AM CST
Oh, I got winded or something. I can’t really remember. I just felt a little short of breath so I used my inhaler to help out. It was just that one time.
When was the last time you used your inhaler Question
01/25/19 3:57 AM CST
Oh, last week probably.
What is the name of the inhaler you’re currently Question
01/25/19 3:57 AM CST
It’s just a regular Proventil inhaler.
How many puffs of your inhaler do you use Question
01/25/19 3:57 AM CST
If I use it, I do 2 or 3 puffs.
Do you know how many posts your inhaler you’re supposed to do (No matching questions found.) Question
01/25/19 3:58 AM CST
how many puffs of your inhaler you’re supposed to do Question
01/25/19 3:58 AM CST
I think it says to do 2 puffs.
Have you use anything to help treat your eye itchiness Question
01/25/19 3:59 AM CST
No, I haven’t done anything to try to make my eyes less itchy.
Have you taken any medication to help your runny nose Question
01/25/19 3:59 AM CST
No, I haven’t taken anything. Most of the stuff you get over-the-counter dries me out too much.
To take any medication like antihistamines to help your symptoms (Clarified to did you take any allergy medication .) Question
01/25/19 3:59 AM CST
I haven’t taken anything yet. I wanted to make sure it was allergies first. (Clarified to if I took allergy medication.)
Do the lozenges help your sore throat that you take Question
01/25/19 4:01 AM CST
Yeah, both throat drops and water help a little bit.
How often do you take lozenges Question
01/25/19 4:01 AM CST
Maybe every few hours.
Are you allergic to any medication Question
01/25/19 4:02 AM CST
Yeah, I’m allergic to penicillin.
Do you experience seasonal allergies (Clarified to do you have seasonal allergies.) Question
01/25/19 4:02 AM CST
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 seasonal allergies.)
Have you experienced any changes in your weight Question
01/25/19 4:03 AM CST
No, I think my weight is about the same.
I’ve got a fever recently Question
01/25/19 4:03 AM CST
No, I haven’t felt feverish at all this week. That’s another reason why this seems more like allergies than a cold.
you are correct to think that. typically a fever is present when someone has a cold Educate
01/25/19 4:04 AM CST
Alright, thanks for letting me know.
it is possible to develop new allergies as an adult Educate
01/25/19 4:04 AM CST
Thanks for telling me.
Have you been fatigued recently Question
01/25/19 4:05 AM CST
No, I don’t feel tired or worn out or anything.
We’ve been sick recently Question
01/25/19 4:05 AM CST
No, I’m usually healthy.
have you been experiencing chills Question
01/25/19 4:05 AM CST
No.
Have you felt nauseous Question
01/25/19 4:06 AM CST
I haven’t had thrown up, or even had an upset stomach, in a long time.
Do you have any troubles with your head (Clarified to have you ever had any problems with your head?.) Question
01/25/19 4:06 AM CST
Just like in general? I get headaches sometimes. (Clarified to if I have had head problems.)
Do you have a headache right now Question
01/25/19 4:06 AM CST
No, I don’t have a headache or anything right now.
An experienced head injury recently (Clarified to have you ever had a head injury.) Question
01/25/19 4:07 AM CST
No, I’ve never had any kind of head injury. (Clarified to if I have had a head injury.)
Do you ever get light-headed Question
01/25/19 4:07 AM CST
No, I don’t ever get light-headed.
How often do you get headaches Question
01/25/19 4:07 AM CST
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 long do headaches usually last Question
01/25/19 4:07 AM CST
A few hours, I guess. I usually take some Tylenol and then go to bed to get rid of them.
How much Tylenol do you usually take Question
01/25/19 4:07 AM CST
I just take one or two of the 500 mg acetaminophen. I usually get the headaches at night from reading — squinting I guess — and so I take one or two and go to bed. [AUDIO COMING SOON]
How would you describe your headaches Question
01/25/19 4:08 AM CST
When I get them, the pain is sort of… tight and throbbing, I guess.
Where do you feel your headache Question
01/25/19 4:08 AM CST
It’s kind of behind my forehead.
Have you any trouble with your eyes Question
01/25/19 4:09 AM CST
You mean, other than this itchy-eye stuff going on right now? I guess… my eyes get blurry sometimes when I read. It seems like my vision is getting worse over the years.
Are you experiencing any eye pain Question
01/25/19 4:09 AM CST
No, my eyes don’t hurt. They’re just itchy.
Do you have dry eyes Question
01/25/19 4:09 AM CST
No.
When was the last time you had a vision test Question
01/25/19 4:09 AM CST
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 wear glasses or contacts Question
01/25/19 4:10 AM CST
No, I’ve never had glasses or contacts.
Can you tell me more about the blurry vision Question
01/25/19 4:10 AM CST
So, I have been noticing this more since I’ve been studying a lot, but when I read for too long, my eyes start to feel tired, and the letters get… fuzzy, I guess. And sometimes I start to get a headache, too.
How long have you been reading when your vision starts to get blurry Question
01/25/19 4:11 AM CST
Sometimes I read for 2 hours or more for school. If I read that much, then I notice it.
Do you get headaches when you also have blurry vision Question
01/25/19 4:11 AM CST
So, I have been noticing this more since I’ve been studying a lot, but when I read for too long, my eyes start to feel tired, and the letters get… fuzzy, I guess. And sometimes I start to get a headache, too.
Have you had any trouble with your ears Question
01/25/19 4:11 AM CST
No, my ears are fine right now.
Do you have any ear pain Question
01/25/19 4:12 AM CST
No, my ears don’t hurt.
Have you had any changes in your hearing Question
01/25/19 4:12 AM CST
No.
Have you noticed any discharge coming from your ears Question
01/25/19 4:12 AM CST
Not that I’ve noticed.
When was your last hearing test Question
01/25/19 4:12 AM CST
It was when I was a kid.
Have you any trouble with your nose recently Question
01/25/19 4:12 AM CST
Yes, my nose won’t stop running!
Have you noticed any changes in your sense of smell Question
01/25/19 4:13 AM CST
Um, I can’t smell quite as well as usual. But I can still smell.
Have you ever had surgery Question
01/25/19 4:13 AM CST
Nope. No surgeries… I’ve been lucky.
Have you ever had nasal surgery Question
01/25/19 4:13 AM CST
No, I’ve never had any surgeries.
Do you get nosebleeds Question
01/25/19 4:13 AM CST
No.
Have you been having any issues with your mouth Question
01/25/19 4:14 AM CST
No.
Has your sense of taste changed Question
01/25/19 4:14 AM CST
No, I can taste fine.
We had a dry mouth recently Question
01/25/19 4:14 AM CST
No.
Do you have any mouth sores Question
01/25/19 4:14 AM CST
No, I haven’t noticed any sores.
Have you had any difficulty swallowing Question
01/25/19 4:14 AM CST
Yes, it hurts my throat to swallow.
Do you have any issues with your gums Question
01/25/19 4:15 AM CST
No, my gums are okay.
Experiencing pain in your mouth (No matching questions found.) Question
01/25/19 4:15 AM CST
Do you have mouth pain Experiencing pain in your mouth Question
01/25/19 4:15 AM CST
No, my mouth feels fine.
Do you have any problems with your tongue Question
01/25/19 4:15 AM CST
No, my tongue is fine.
Daily problems with your jaw (Clarified to Do you have jaw pain?.) Question
01/25/19 4:16 AM CST
No, my jaw doesn’t hurt. (Clarified to if I have jaw pain.)
Do you have any dental problems Question
01/25/19 4:16 AM CST
No, I’ve got good teeth. They don’t give me any problems.
When was the last time you saw dentist Question
01/25/19 4:16 AM CST
Um, I think the last time was a few years ago. I went twice a year as a kid, though.
Have you had any trouble with your throat Question
01/25/19 4:17 AM CST
Yes, my throat’s sore right now.
Do you get strep throat often Question
01/25/19 4:17 AM CST
No, I don’t remember the last time I had anything wrong with my throat.
Do you have any problems with your lymph nodes Question
01/25/19 4:17 AM CST
I think my lymph nodes are fine.
Give a history of throat problems (Clarified to Do you have a history of throat problems.) Question
01/25/19 4:17 AM CST
Sometimes I get a sore throat when I have a cold, but I wouldn’t say I have any consistent throat problems or anything. (Clarified to if I have a history of throat problems.)
Has your voice changed lately (Clarified to have you had changes in your voice.) Question
01/25/19 4:17 AM CST
No, my voice is fine. Same as usual. (Clarified to if I have had changes in my voice.)
Do you have any history of tonsil problems Question
01/25/19 4:18 AM CST
No, my tonsils are fine — as far as I know, I’ve never had problems with my tonsils.
do you have any neck pain Question
01/25/19 4:18 AM CST
No, my neck feels fine.
Does your family have a history of sinus issues Question
01/25/19 4:19 AM CST
No… My sister gets hay fever sometimes but that’s all I know about.
Division problems are in your family (No matching questions found.) Question
01/25/19 4:19 AM CST
Do vision problems are in your family Question
01/25/19 4:19 AM CST
No.
Do hearing problems run in your family Question
01/25/19 4:19 AM CST
No.
Does does migraine or headaches from your family (No matching questions found.) Question
01/25/19 4:20 AM CST
Do you have a family history of throat problems Question
01/25/19 4:20 AM CST
No.
Give a family history of headaches Question
01/25/19 4:20 AM CST
No, not that I know of.
How often do your eyes itch Question
01/25/19 4:22 AM CST
Yeah, it’s all the time.
I’m sorry to hear about your itchy eyes. I know that can be frustrating Empathize
01/25/19 4:22 AM CST
I appreciate you saying that.
Ms. Jones I’m going to start your physical assessment now. thank you for answering all of my questions Educate
01/25/19 4:23 AM CST
Sure, I think I understand what you mean.
 Inspected general face Exam Action
01/25/19 4:47 AM CST
 Inspected forehead and scalp Exam Action
01/25/19 4:47 AM CST
 Inspected nose and mouth Exam Action
01/25/19 4:47 AM CST
 Inspected left side of face Exam Action
01/25/19 4:47 AM CST
 Inspected general face Exam Action
01/25/19 4:47 AM CST
 Inspected right side of face Exam Action
01/25/19 4:47 AM CST
 Inspected upper conjunctiva Exam Action
01/25/19 4:48 AM CST
 Inspected right orbital area and sclera Exam Action
01/25/19 4:48 AM CST
 Inspected left orbital area and sclera Exam Action
01/25/19 4:48 AM CST
 Inspected lower conjunctiva Exam Action
01/25/19 4:48 AM CST
 Inspected upper conjunctiva Exam Action
01/25/19 4:48 AM CST
 Performed otoscopic examination of right naris Exam Action
01/25/19 4:48 AM CST
 Performed otoscopic examination of left naris Exam Action
01/25/19 4:48 AM CST
 Performed otoscopic examination of left ear Exam Action
01/25/19 4:49 AM CST
 Performed otoscopic examination of right ear Exam Action
01/25/19 4:49 AM CST
 Performed otoscopic examination of left ear Exam Action
01/25/19 4:49 AM CST
 Inspected mouth Exam Action
01/25/19 4:49 AM CST
 Inspected mouth: pushed tongue left with tongue blade Exam Action
01/25/19 4:49 AM CST
 Inspect mouth: pushed tongue right with tongue blade Exam Action
01/25/19 4:50 AM CST
 Inspect mouth: lifted tongue with tongue blade Exam Action
01/25/19 4:50 AM CST
 Inspected mouth: depressed tongue with tongue blade Exam Action
01/25/19 4:50 AM CST
 Inspected front of neck Exam Action
01/25/19 4:50 AM CST
 Inspected left side of neck Exam Action
01/25/19 4:51 AM CST
 Inspected front of neck Exam Action
01/25/19 4:51 AM CST
 Inspected right side of neck Exam Action
01/25/19 4:51 AM CST
 Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported Exam Action
01/25/19 4:51 AM CST
 Palpated frontal sinuses: No tenderness reported Exam Action
01/25/19 4:51 AM CST
 Palpated maxillary sinuses: No tenderness reported Exam Action
01/25/19 4:51 AM CST
 Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+ Exam Action
01/25/19 4:51 AM CST
 Palpated left carotid artery: No thrill, 2+ Exam Action
01/25/19 4:52 AM CST
 Palpated right carotid artery: No thrill, 2+ Exam Action
01/25/19 4:52 AM CST
 Palpated jaw: Full range of motion, no popping or clicking Exam Action
01/25/19 4:52 AM CST
 Palpated lymph nodes of head and neck: Not palpable Exam Action
01/25/19 4:53 AM CST
 Palpated supraclavicular lymph nodes: Not palpable Exam Action
01/25/19 4:53 AM CST
 Palpated axillary lymph nodes: Not palpable Exam Action
01/25/19 4:53 AM CST
 Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported Exam Action
01/25/19 4:53 AM CST
 Auscultated breath sounds in anterior left upper lobe Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in anterior right upper lobe Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in anterior right middle lobe Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in anterior left lower lobe Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in anterior right lower lobe Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in posterior right upper lobe Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in posterior left mid-back (lower lobe) Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in posterior left upper lobe Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in posterior right mid-back (lower lobe) Shadow Health HEENT Focused Exam Transcript Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in posterior right lower lobe Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in posterior right lower lobe near spine Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in posterior right lower lobe on side Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in posterior left lower lobe Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in posterior left lower lobe on side Exam Action
01/25/19 4:54 AM CST
 Auscultated breath sounds in posterior left lower lobe near spine Exam Action
01/25/19 4:54 AM CST
 Auscultated left temporal pulse Exam Action
01/25/19 4:55 AM CST
 Auscultated right temporal pulse Exam Action
01/25/19 4:55 AM CST
 Auscultated left carotid pulse Exam Action
01/25/19 4:55 AM CST
 Auscultated right carotid pulse Exam Action
01/25/19 4:55 AM CST
 Tested left pupillary reaction with penlight Exam Action
01/25/19 4:55 AM CST
 Tested right pupillary reaction with penlight Exam Action
01/25/19 4:55 AM CST
Pull my finger with just your eyes. Shadow Health HEENT Focused Exam Transcript Question
01/25/19 4:56 AM CST
Ok.
 Tested EOM to the upper right Exam Action
01/25/19 4:56 AM CST
 Tested convergence to the center Exam Action
01/25/19 4:56 AM CST
 Tested EOM to the upper left Exam Action
01/25/19 4:56 AM CST
 Tested EOM to the lower left Exam Action
01/25/19 4:56 AM CST
 Tested EOM to the upper center Exam Action
01/25/19 4:56 AM CST
 Tested EOM to the lower center Exam Action
01/25/19 4:56 AM CST
 Tested EOM to the lower right Exam Action
01/25/19 4:56 AM CST
Tell me when you can no longer see my fingers Question
01/25/19 4:56 AM CST
Ok, I will.
 Tested peripheral vision Exam Action
01/25/19 4:56 AM CST
Now.
 Examined fundus of right eye with ophthalmoscope Exam Action
01/25/19 4:57 AM CST
 Examined fundus of left eye with ophthalmoscope Exam Action
01/25/19 4:57 AM CST
F P
F P
T O Z
L P E D
P E C F D
E D F C Z P
F E L O P Z D
D E F P O T E C
 Tested visual acuity of left eye (right eye covered) Exam Action
01/25/19 4:59 AM CST
F P
T O Z
L P E D
P E C F D
 Tested visual acuity of right eye (left eye covered) Exam Action
01/25/19 4:59 AM CST
E D E O X F
Is the volume the same in both ears or louder in one ear Question
01/25/19 5:00 AM CST
Ok.
Same in both ears.
 Performed Weber test with tuning fork Exam Action
01/25/19 5:00 AM CST
Tell me when you no longer hear the ringing Question
01/25/19 5:00 AM CST
Ok, I will.
Now.
 Performed Rinne test on left ear with tuning fork Exam Action
01/25/19 5:01 AM CST
Now.
Tell me when you no longer hear the ringing Question
01/25/19 5:01 AM CST
Ok, I will.
Now.
 Performed Rinne test on right ear with tuning fork Exam Action
01/25/19 5:02 AM CST
Now.
Four Question
01/25/19 5:02 AM CST
Four.
R. Question
01/25/19 5:02 AM CST
R.
Nine. Question
01/25/19 5:02 AM CST
Nine.
 Performed whisper test in left ear. Shadow Health HEENT Focused Exam Transcript Exam Action
01/25/19 5:02 AM CST
F. Question
01/25/19 5:03 AM CST
F.
Eight Question
01/25/19 5:03 AM CST
Eight.
W. Question
01/25/19 5:03 AM CST
W.
 Performed whisper test in right ear Exam Action
01/25/19 5:03 AM CST
 Tested gag reflex with tongue blade Exam Action
01/25/19 5:03 AM CST
Ms. Jones I’ve completed your physical assessment. Based on what I’ve noticed your red eyes, redness and swollen tonsils, you are showing all the classic signs of seasonal allergies. Educate
01/25/19 5:07 AM CST
OK, I understand.
I would like you to keep a journal all your allergic symptoms when you have them and what brought on those symptoms. I would like you to bring the journal with you to your next visit with me. Avoid any allergy trigger the best you can. I’m also going to prescribe you a medication called Claritin that you will take daily to treat your allergy symtpoms. Educate
01/25/19 5:09 AM CST
Thanks for telling me.
I would like you to follow up with me in 2-4 weeks to see if your symptoms get better. In the mean time if you develop a fever, worsening headaches, or any other problems I want you to seek care earlier. (No matching questions found.) Question
01/25/19 5:10 AM CST
I would like you to follow up with me in 2-4 weeks to see if your symptoms get better. In the mean time if you develop a fever, worsening headaches, or any other problems I want you to seek care earlier. Educate
01/25/19 5:11 AM CST
Alright, thanks for letting me know.
Also I noticed you vision in your right eye is worse than your left so I would recommend that you go see an eye doctor to be evaluated to see if you need glasses. It may help the headaches you develop when you are studying Educate
01/25/19 5:12 AM CST
That makes sense.
Do you have any questions? Question
01/25/19 5:12 AM CST
I don’t have any questions.
I would also like you to increase your water intake (No matching questions found.) Question
01/25/19 5:13 AM CST
I would also like you to increase your water intake Educate
01/25/19 5:13 AM CST
Sure, I think I understand what you mean.
any questions? Question
01/25/19 5:13 AM CST
I don’t have any questions.
Alright then I’ll see you in 2-4 weeks unless you need to see me before then Educate
01/25/19 5:14 AM CST
OK, I understand.

 

 

 

 

 

 

 

Subjective Data Collection

Chief Complaint

Finding:

Established chief complaint

Finding:

Reports sore throat

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question:

Is your throat sore?

Finding:

Reports itchy throat

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Shadow Health HEENT Focused Exam Transcript

Example Question:

Is your throat itchy?

Finding:

Reports itchy eyes

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Shadow Health HEENT Focused Exam Transcript

Example Question:

Are your eyes itchy?

Finding:

Reports runny nose

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question:

Do you have a runny nose?

History of Present Illness

Finding:

Asked about onset of symptoms

Finding:

Reports sore throat began “about a week ago”

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s throat has been sore will also aid in treating her sore throat.

Example Question:

How long has your throat been sore?

Finding:

Reports runny nose began “about a week ago”

(Found)

Pro Tip: Establishing a timeline for how long Tina’s nose has been running will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

When did your nose start running?

Finding:

Reports itchy eyes began “about a week ago”

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s eyes have been itching will also aid in treating her itchy eyes.

Example Question:

When did your eyes start itching?

Finding:

Asked about aggravating factors for throat symptoms

Finding:

Reports throat pain is constant

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s throat has been sore will also aid in treating her sore throat.

Example Question:

Is the throat pain constant?

Finding:

Reports throat pain is worse in the morning

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s throat has been sore will also aid in treating her sore throat.

Example Question:

When does your sore throat feel the worst?

Finding:

Reports some soreness with swallowing

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Does it hurt when you swallow?

Finding:

Asked severity of throat discomfort

Finding:

Describes sore throat as mild to moderate

(Found)

Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.

Example Question:

Can you rate your sore throat on a scale of 0 to 10?

Finding:

Asked about frequency and duration of runny nose

Finding:

Reports nose is runny “pretty much all day”

(Found)

Pro Tip: Establishing a timeline for how long Tina’s nose has been running will illustrate how long she has been suffering these particular symptoms, when the symptoms are worst, and possible triggers.

Example Question:

How often does your nose run?

Finding:

Asked about character of nasal symptoms

Finding:

Denies itchy nose

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Does your nose itch?

Finding:

Denies sinus pain

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Do you feel any sinus pain?

Finding:

Denies sinus pressure

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Do you feel any sinus pressure?

Finding:

Denies sneezing

(Found)

Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems.

Example Question:

Have you been sneezing?

Finding:

Followed up about character of nasal discharge

Finding:

Reports clear discharge

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

What color is your mucus?

Finding:

Reports thin discharge

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Is the mucus thick?

Finding:

Denies purulent discharge

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Shadow Health HEENT Focused Exam Transcript

Example Question:

Does your mucus have pus in it?

Finding:

Asked about eye symptoms

Finding:

Reports eye itching is constant

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Determining when Tina’s eyes most itch will also aid in treating her itchy eyes.

Example Question:

Do your eyes constantly itch?

Finding:

Reports eye redness

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Are your eyes red?

Finding:

Asked related respiratory symptoms

Finding:

Reports breathing isn’t affected

(Found)

Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns or conditions.

Example Question:

Have you had any changes in your breathing?

Finding:

Denies cough

(Found)

Pro Tip: A shallow history of a patient’s condition can provide a comparative baseline for juxtaposing an attack, exacerbation, and more regular breathing. Soliciting this information from Tina allows her to explain any recent developments with her asthma.

Example Question:

Do you have a cough?

Finding:

Denies chest tightness

(Found)

Pro Tip: For many patients with asthma, exacerbation often results in chest tightness. Asking Tina if her chest feels tight might point to possible asthma symptoms.

Example Question:

Does your chest feel tight?

Finding:

Asked about related asthma symptoms

Finding:

Denies recent wheezing

(Found)

Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and thus might not volunteer this information. Asking Tina whether she has been wheezing illustrates how her asthma is presenting.

Example Question:

Have you been wheezing?

Finding:

Denies increase in recent asthma symptoms

(Found)

Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.

Example Question:

Has your asthma been worse lately?

Finding:

Asked about exposure to allergens

Finding:

Reports no exposure to cats

(Found)

Pro Tip: Tina’s symptoms are consistent with being exposed to allergens. Asking Tina if she’s recently been exposed to allergens could explain what’s triggering her symptoms.

Example Question:

Have you been recently exposed to any allergens?

Finding:

Reports no exposure to mold or mildew

(Found)

Pro Tip: Exposure to mold can result in painful ear, nose, or throat symptoms. Asking Tina if she has mold in her house might indicate a possible trigger that she has been exposed to.

Example Question:

Do you have mold in your house?

Finding:

Reports no exposure to dust

(Found)

Pro Tip: Exposure to dust can result in painful ear, nose, or throat symptoms. Asking Tina if she has dust in her house might indicate a possible trigger that she has been exposed to.

Example Question:

Do you have dust in your house?

Finding:

Reports no known exposure to irritants in work environment

(Found)

Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation. Shadow Health HEENT Focused Exam Transcript

Example Question:

Are you allergic to anything at work?

Finding:

Reports changing bedding “once a week”

(Found)

Pro Tip: Bedding provides the perfect environment for dust mites and other allergens. By asking Tina if she regularly changes her bedding, you’re soliciting information about environmental factors that might exacerbate her condition.

Example Question:

How often do you change your bedding?

Finding:

Asked about perceived cause of symptoms

Finding:

Describes symptoms as similar to allergies

(Found)

Pro Tip: Questions about what factors might have caused certain symptoms can point to a patient’s environmental stressors, habits, and general wellbeing. Asking Tina what caused her asthma might indicate her health literacy and understanding of what factors impact her breathing.

Example Question:

Do you know what’s causing your symptoms?

Finding:

Reports that the symptoms don’t seem like a common cold

(Found)

Pro Tip: A patient is an expert on her body. Asking Tina if she thinks she has a cold will give Tina the opportunity to compare her current symptoms with cold symptoms she’s historically had and describe if her current symptoms differ from those she experiences when she has a cold.

Example Question:

Do you think you have a cold?

Finding:

Describes similarity to her sister’s hay fever symptoms

(Found)

Pro Tip: A patient is an expert on her body. Asking Tina if she thinks she is having an allergic reaction will give Tina the opportunity to compare her current symptoms with symptoms she’s historically had during an allergic reaction.

Example Question:

Do you think you are having an allergic reaction?

Finding:

Reports no history of cigarette smoking

(Found)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she has recently smoked can help you to discern whether smoking was a factor in Tina’s recent asthma exacerbation.

Example Question:

Have you smoked cigarettes recently?

Finding:

Reports no recent exposure to secondhand smoke

(Found)

Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking whether Tina has been exposed to secondhand smoke might indicate a proximate environmental trigger.

Example Question:

Have you been exposed to secondhand smoke recently? Shadow Health HEENT Focused Exam Transcript

Medical History

Finding:

Confirmed use of medications

Finding:

Confirmed medications from previous visit (no new medications)

(Found)

Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.

Example Question:

Have you started taking any new medications?

Finding:

Followed up about inhaler use

Finding:

Uses an inhaler to treat asthma symptoms

(Found)

Pro Tip: It’s essential to ask specifically what medications a patient is using to treat her current complaint or any ongoing medical conditions.

Example Question:

Do you use an inhaler for your asthma?

Finding:

Inhaler is Proventil

(Found)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it.

Example Question:

What is the name of the inhaler you are currently using?

Finding:

Last use of inhaler was last week

(Found)

Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.

Example Question:

When did you last use your inhaler?

Finding:

Reports typical inhaler use is 2 – 3 times a week

(Available)

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.

Example Question:

How often do you use your inhaler?

Finding:

Reports using 2 – 3 puffs of inhaler when used

(Found)

Pro Tip: Inhaler effectiveness can vary over time for a variety of reasons. Asking Tina about the number on inhaler puffs she needs to resolve symptoms can indicate whether her asthma has worsened or point to potential problems like poor inhaler technique.

Example Question:

How many puffs of your inhaler do you use?

Finding:

Prescribed dosage is 2 puffs

(Found)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how many puffs of her inhaler she’s prescribed will indicate her treatment plan and the degree to which she complies with it.

Example Question:

How many puffs of your inhaler are you supposed to do?

Finding:

Followed up about medications and relieving factors for nose and eye symptoms

Finding:

Reports no treatment for itchy eyes

(Found)

Pro Tip: Tina’s response to a question about managing her itchy eyes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Have you treated your eyes with anything?

Finding:

Reports no treatment for nasal symptoms

(Found)

Pro Tip: Tina’s response to a question about managing her runny nose will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Have you done anything for your runny nose?

Finding:

Reports no antihistamine

(Found)

Pro Tip: Tina’s response to a question about taking any antihistamines will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Have you taken any antihistamines?

Finding:

Reports no decongestant

(Available)

Pro Tip: Tina’s response to a question about taking any decongestants will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Have you taken any decongestants?

Finding:

Followed up about medications and relieving factors for throat symptoms

Finding:

Reports lozenges as treatment

(Found)

Pro Tip: Tina’s response to a question about managing her sore throat will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Have you taken anything for your sore throat?

Finding:

Reports lozenges reduce symptoms

(Found)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if the lozenges help will illustrate the extent of her pain and how effectively OTC treatments works for her throat.

Example Question:

Do the lozenges help?

Finding:

Reports ingesting lozenges every few hours

(Found)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how frequently she has a lozenge will illustrate the extent of her pain and how effectively OTC treatment works for her throat. Shadow Health HEENT Focused Exam Transcript

Example Question:

How often do you have a lozenge?

Finding:

Reports drinking water reduces symptoms

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Does drinking water help?

Finding:

Confirmed allergies

Finding:

Reports known allergy to cats

(Found)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a cat allergy can reveal one such trigger.

Example Question:

Can you confirm that you’re allergic to cats?

Finding:

Reports known allergy to dust

(Found)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a dust allergy can reveal one such trigger.

Example Question:

Are you allergic to dust?

Finding:

Reports no previous problems with seasonal allergies

(Found)

Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movement that may have a bearing on Tina’s breathing. Asking Tina whether she has seasonal triggers will indicate, in part, Tina’s health literacy.

Example Question:

Do you have seasonal allergies?

Review of Systems

Finding:

Asked about general symptoms

Finding:

Denies recent or frequent illnesses

(Found)

Pro Tip: Asking about recent illnesses can give help you determine the cause of a patient’s symptoms.

Example Question:

Have you been sick recently?

Finding:

Denies chills

(Found)

Pro Tip: Chills could be an indication of fever, which could be an indication of infection.

Example Question:

Have you had any chills?

Finding:

Denies fever

(Found)

Pro Tip: Fever could signal that the patient’s symptoms are caused by an infection.

Example Question:

Have you had a fever?

Finding:

Reports low energy level

(Found)

Pro Tip: Low energy or fatigue can be an important symptoms or contributing factor to discover, and can help you rule out certain conditions.

Example Question:

Have you felt fatigued?

Finding:

Denies nausea or vomiting

(Found)

Pro Tip: Nausea or vomiting can indicate an infection.

Example Question:

Have you felt nauseous?

Finding:

Asked about review of systems for head

Finding:

Reports occasional headaches

(Found)

Pro Tip: Sinus problems can result in increased pressure buildup and headaches. Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences.

Example Question:

Do you ever get headaches?

Finding:

Denies current headache

(Found)

Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Asking Tina if she currently has a headache solicits information about how she is feeling now.

Example Question:

Do you have a headache currently?

Finding:

Denies history of head injury

(Found)

Pro Tip: People who’ve experienced head injuries are at increased risk for sinusitis. Asking Tina whether she’s ever had a head injury solicits health history information that might explain the cause of her symptoms.

Example Question:

Have you ever had a head injury?

Finding:

Denies lightheadedness

(Found)

Pro Tip: Sinus infections can result in inner ear disturbances and thus lightheadedness. Asking Tina if she is lightheaded could point to inner ear disturbances.

Example Question:

Do you ever get lightheaded?

Finding:

Followed up on headaches

Finding:

Headaches occur once a week

(Found)

Pro Tip: Establishing a timeline for how often Tina gets headaches will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

How often do you get headaches?

Finding:

Headaches last “a few hours”

(Found)

Pro Tip: Establishing a timeline for how long Tina’s headaches last will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

How long do your headaches last?

Finding:

Describes headaches as tight and throbbing

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Shadow Health HEENT Focused Exam Transcript

Example Question:

How would you describe your headaches?

Finding:

Describes headache location as behind her forehead

(Found)

Pro Tip: Specifying the location of pain can narrow and define where Tina’s pain is occurring. Soliciting this information allows you to more accurately treat her symptoms.

Example Question:

Where do you feel your headaches?

Finding:

Rates headache pain as a 3 or 4

(Available)

Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.

Example Question:

How would you rate your headache pain on a scale of 0 to 10?

Finding:

Reports treating headaches with Tylenol

(Found)

Pro Tip: Tina’s response to a question about managing her headaches will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

How do you treat your headaches?

Finding:

Reading and studying seem to cause headaches

(Found)

Pro Tip: Soliciting information about possible headache triggers will allow Tina to consider what, if any, activities, weather patterns, movements, or sensory input is correlated with her headaches.

Example Question:

What seems to cause your headaches?

Finding:

Asked about review of systems for eyes

Finding:

Reports occasional blurry vision

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Do you have blurry vision?

Finding:

Reports worsening vision

(Found)

Pro Tip: Establishing a timeline for whether Tina’s vision has gotten worse will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

Has your vision gotten worse?

Finding:

Denies eye pain

(Found)

Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Tina whether she is experiencing eye pain solicits information about possible symptoms.

Example Question:

Have you had eye pain?

Finding:

Denies dry eyes

(Found)

Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Asking Tina if she has dry eyes solicits information about one particular symptom.

Example Question:

Have you had dry eyes?

Finding:

Reports last vision exam was in childhood

(Found)

Pro Tip: Asking Tina when her last vision test was will indicate the degree to which she’s seen her vision as something that has needed medical attention.

Example Question:

When was your last vision test?

Finding:

Does not use corrective lenses

(Found)

Pro Tip: Corrective lenses might indicate a recent change in vision. Asking Tina whether she has glasses or contacts solicits information about her vision history.

Example Question:

Do you have glasses or contacts?

Finding:

Followed up on vision problems

Finding:

Describes blurry vision as “fuzzy letters” Shadow Health HEENT Focused Exam Transcript

(Found)

Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.

Example Question:

Can you describe your blurry vision?

Finding:

Blurry vision occurs when reading for long periods

(Found)

Pro Tip: Establishing a timeline for how frequently Tina gets blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

When do you get blurry vision?

Finding:

Blurry vision occurs after 2+ hours of reading

(Found)

Pro Tip: Establishing a timeline for how long Tina’s vision stays blurry will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

How long have you been reading when your vision gets blurry?

Finding:

Reports that blurry vision and headaches often coincide

(Found)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Do you get headaches when you have blurry vision?

Finding:

Asked about review of systems for ears

Finding:

Denies general ear problems

(Found)

Pro Tip: Soliciting a shallow medical history relevant to Tina’s chief complaint will allow you to assess her condition relative to past concerns.

Example Question:

Have you had ear problems?

Finding:

Denies change in hearing

(Found)

Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing.

Example Question:

Have you had any changes in your hearing?

Finding:

Denies ear pain

(Found)

Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous. Asking Tina if she has ear pain might indicate a possible ear infection.

Example Question:

Have you had ear pain?

Finding:

Denies ear discharge

(Found)

Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer’s ear. Asking whether she’s noticed ear discharge could indicate whether she has a ruptured eardrum.

Example Question:

Have you noticed ear discharge?

Finding:

Reports last hearing test was in childhood

(Found)

Pro Tip: Asking Tina when her last hearing test was will indicate the degree to which she’s seen her hearing as something that has needed medical attention Shadow Health HEENT Focused Exam Transcript.

Example Question:

When was your last hearing test?

Finding:

Asked about review of systems for nose

Finding:

Denies change in sense of smell

(Found)

Pro Tip: Changes in sense of smell could be a symptom of acute sinusitis. Asking Tina if she’s had any changes in her sense of smell indicates whether she might be suffering from acute sinusitis.

Example Question:

Have you had any changes in your sense of smell?

Finding:

Reports no nasal or sinus surgeries

(Found)

Pro Tip: A history of nasal surgery might indicate that Tina had chronic nasal problems. Asking Tina if she’s ever had nasal surgery solicits information about her medical history.

Example Question:

Have you ever had a nasal surgery?

Finding:

Denies nosebleeds

(Found)

Pro Tip: Nosebleeds are often caused by sinusitis. Asking Tina if she ever gets nosebleeds solicits information about her medical history.

Example Question:

Do you ever get nosebleeds?

Finding:

Asked about review of systems for mouth and jaw

Finding:

Denies general mouth problems

(Found)

Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.

Example Question:

Have you ever had problems with your mouth?

Finding:

Denies change in sense of taste

(Found)

Pro Tip: Sinusitis can result in decreased smell or taste. Asking if Tina’s sense of taste has changed lately might indicate a sign of sinusitis.

Example Question:

Has your sense of taste changed?

Finding:

Denies dry mouth

(Found)

Pro Tip: Sinusitis can result in dry mouth. Asking if Tina’s recently had dry mouth might indicate a sign of sinusitis.

Example Question:

Have you had dry mouth recently?

Finding:

Denies history of oral surgery

(Available)

Pro Tip: A history of oral surgery might indicate that Tina had former oral problems. Asking Tina if she’s ever had oral surgery solicits information about her medical history.

Example Question:

Have you ever had oral surgery?

Finding:

Denies mouth pain

(Found)

Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she’s had mouth pain might indicate a problem area that has caused infection.

Example Question:

Do you have mouth pain?

Finding:

Denies mouth sores

(Found)

Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. Asking Tina if she has any mouth sores might indicate a problem area that has caused infection.

Example Question:

Do you have any mouth sores?

Finding:

Denies gum problems

(Found)

Pro Tip: If left untreated, gum problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms.

Example Question:

Do you have any problems with your gums?

Finding:

Denies tongue problems

(Found)

Pro Tip: If left untreated, tongue problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms.

Example Question:

Do you have any problems with your tongue?

Finding:

Denies jaw problems

(Found)

Pro Tip: If left untreated, jaw problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her jaw solicits information about possible causes of her symptoms.

Example Question:

Do you have any problems with your jaw?

Finding:

Asked about review of systems for dentation

Finding:

Denies current dental problems

(Found)

Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she has any dental problems might indicate a problem area that has caused infection.

Example Question:

Do you have any current dental problems?

Finding:

Reports visit within the last 2 years

(Found)

Pro Tip: Seeing a dentist regularly can assure that among other things, tooth infections, which can cause sinusitis, do not go untreated. Asking Tina when she last saw a dentist will reveal her health literacy and indicate whether or not her mouth is a problem area.

Example Question:

When did you last see the dentist?

Finding:

Reports regular visits in childhood

(Found)

Pro Tip: Seeing a dentist regularly as a child can lay the foundation for good dental hygiene and prevent infection. Asking Tina how often she saw the dentist as a child will suggest her health and dental history.

Example Question:

How often did you see the dentist when you were a child?

Finding:

Reports a few cavities in childhood

(Available)

Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina what dental problems she’s had might indicate a problem area that has caused infection.

Example Question:

What dental problems have you had?

Finding:

Asked about review of systems for neck, throat and glands

Finding:

Denies history of recurrent strep throat

(Found)

Pro Tip: Soliciting a shallow medical history relevant to Tina’s chief complaint will allow you to assess her condition relative to past concerns.

Example Question:

Do you get strep throat often?

Finding:

Denies lymph node problems

(Found)

Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether she has had any problems with her lymph nodes will solicit a history of her condition.

Example Question:

Do you have any problems with your lymph nodes?

Finding:

Denies history of general throat problems

(Found)

Pro Tip: Throat problems are often linked to sinusitis. Asking Tina if she has a history of throat problems will illustrate her medical history in relation to similar concerns. Shadow Health HEENT Focused Exam Transcript

Example Question:

Do you have a history of throat problems?

Finding:

Denies voice changes

(Found)

Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems.

Example Question:

Have you noticed any changes to your voice?

Finding:

Denies history of tonsil problems

(Found)

Pro Tip: Sinusitis can often lead to tonsil problems. Asking Tina if she has a history of tonsil problems would reveal whether problems with her sinuses have led to tonsil problems.

Example Question:

Do you have any history of tonsil problems?

Finding:

Denies general neck pain

(Found)

Pro Tip: Neck pain, soreness, or soft tissue damage might result in sinus pain. Asking Tina if she has neck pain is soliciting information about a possible cause of her symptoms.

Example Question:

Do you have neck pain?

Family History

Finding:

Asked about relevant family history

Finding:

Reports sister with hay fever

(Found)

Pro Tip: A family history of allergies is an important factor to determine whether a patient is at risk for developing allergies.

Example Question:

Do you have any family members with allergies?

Finding:

Denies family history of vision problems

(Found)

Pro Tip: Vision problems are often genetic. Learning about a patient’s family history around vision can help you predict risk.

Example Question:

Do vision problems run in your family?

Finding:

Denies family history of sinus problems

(Found)

Pro Tip: Sinus problems are often genetic. Learning about a patient’s family history around sinus problems can help you predict risk.

Example Question:

Do sinus problems run in your family?

Denies family history of sinus problems (Found)

Subjective Action

Pro Tip: Sinus problems are often genetic. Learning about a patient’s family history around sinus problems can help you predict risk.

Example Question: “Do sinus problems run in your family?”

Finding:

Denies family history of ear or hearing problems

(Found)

Pro Tip: Ear problems are often genetic. Learning about a patient’s family history around ear problems can help you predict risk.

Example Question:

Do hearing problems run in your family?

Finding:

Denies family history of mouth, throat, or gland problems

(Found)

Pro Tip: Because problems like mouth or throat cancer can be genetic, it’s important to understand family history to determine risk factors.

Example Question:

Do you have any family history of throat problems?

Finding:

Denies family history of headache or migraine

 

 

 

 

 

 

 

 

 

 

Objective Data Collection

  •  Correct
  •  Partially correct
  • Incorrect
  • Missed

 Inspected head and face

0.67 of 1 point

 

Skull Symmetry (1/3 point)

  •  Symmetric
  •  Asymmetric

Facial Feature Symmetry (1/3 point)

  • Symmetric
  • Asymmetric

Appearance (No point)

  •  No visible abnormal findings
  •  Rash
  •  Papules, pustules, or comedones
  •  Skin growths (freckles, moles, or birthmarks)
  •  Excessive hair growth
  •  Evidence of skin trauma (scar, laceration, or bruising)
  •  Red, chapped nose

 Inspected eyes and orbital area

0.75 of 1 point

 

Orbital Area (No point)

  •  No visible abnormal findings
  •  Ptosis
  •  Eyelid edema
  •  Lesion
  •  Allergic shiners

Sclera (1/4 point)

  • White
  • Injection
  • Icterus

Conjunctiva (1/4 point) Shadow Health HEENT Focused Exam Transcript

  •  Moist and pink
  •  Pale
  •  Dry appearance
  •  Erythema
  •  Edema

Conjunctival Discharge (1/4 point)

  • No discharge
  • Clear, watery discharge
  • Purulent discharge

 Inspected nasal cavities

0.75 of 1 point

 

Color (No point)

  •  Pink
  •  Pale
  •  Erythemic
  •  Bluish

Discharge (1/4 point)

  • No discharge
  • Clear discharge
  • Bloody discharge
  • Purulent discharge

Turbinate Patency (1/4 point)

  •  Patent
  •  Decreased patency
  •  Not patent

Observations (1/4 point)

  • No additional visible abnormal findings
  • Foreign body present
  • Polyp
  • Septum perforated
  • Septum deviated
  • Lesion

 Inspected ears

1 of 1 point

 

Right: Auditory Canal Color (1/10 point)

  •  Pink
  •  Red
  •  Pallor

Right: Tympanic Membrane Color (1/10 point) Shadow Health HEENT Focused Exam Transcript

  • Pearly gray
  • Red
  • Opaque
  • Yellow
  • Not visible because of cerumen

Right: Tympanic Membrane Appearance (1/10 point)

  •  No visible abnormal findings
  •  Fluid observed
  •  Visible scars
  •  Bulging
  •  Perforation
  •  Retraction

Right: Cone Of Light (1/10 point)

  • 5:00
  • Cone of light distorted

Right: Discharge (1/10 point)

  •  No discharge
  •  Cerumen
  •  Clear discharge
  •  Bloody discharge
  •  Purulent discharge

Left: Auditory Canal Color (1/10 point)

  • Pink
  • Red
  • Pallor

Left: Tympanic Membrane Color (1/10 point)

  •  Pearly gray
  •  Red
  •  Opaque
  •  Yellow
  •  Not visible because of cerumen

Left: Tympanic Membrane Appearance (1/10 point)

  • No visible abnormal findings
  • Fluid observed
  • Visible scars
  • Bulging
  • Perforation
  • Retraction

Left: Cone Of Light (1/10 point)

  •  7:00
  •  Cone of light distorted

Left: Discharge (1/10 point)

  • No discharge
  • Cerumen
  • Clear discharge
  • Bloody discharge
  • Purulent discharge

 Inspected mouth and throat

0.83 of 1 point

 

Oral Mucosa (No point)

  •  Moist and pink
  •  Dry appearance
  •  Erythemic

Tonsils (1/6 point)

  • No visible abnormal findings
  • Edema
  • Erythema

Tonsil Grade (1/6 point)

  •  0: Tonsils fit within tonsillar fossa
  •  1+: Tonsils <25% of space between pillars
  •  2+: Tonsils <50% of space between pillars
  •  3+: Tonsils <75% of space between pillars
  •  4+: Tonsils >75% of space between pillars

Posterior Oropharynx Color (1/6 point)

  • Pink
  • Erythemic

Posterior Oropharynx Texture (1/6 point)

  •  No abnormal findings
  •  Cobblestoning
  •  Exudate

Post Nasal Drip (1/6 point)

  • No discharge
  • Clear discharge
  • Purulent discharge

 Inspected neck

1 of 1 point

 

Symmetry (1/2 point)

  •  Symmetric
  •  Asymmetric

Appearance (1/2 point)

  • No visible abnormal findings
  • Swelling
  • Visible pulsation
  • Visible mass
  • Discoloration

 Palpated scalp

1 of 1 point

 

Tenderness (1/2 point)

  •  None reported
  •  Tenderness reported

Observations (1/2 point) Shadow Health HEENT Focused Exam Transcript

  • No additional abnormal findings
  • Balding or thinning areas in hair distribution
  • Palpable masses

 Palpated sinuses

1 of 1 point

 

Frontal (1/2 point)

  •  None reported
  •  Tenderness reported

Maxillary (1/2 point)

  • None reported
  • Tenderness reported

 Palpated temporal arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Intensity (1/4 point)

  • 0 Absent
  • 1+ Diminished or barely palpable
  • 2+ Expected
  • 3+ Increased
  • 4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Intensity (1/4 point)

  • 0 Absent
  • 1+ Diminished or barely palpable
  • 2+ Expected
  • 3+ Increased
  • 4+ Bounding pulse

 Palpated carotid arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Intensity (1/4 point)

  • 0 Absent
  • 1+ Diminished or barely palpable
  • 2+ Expected
  • 3+ Increased
  • 4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Intensity (1/4 point)

  • 0 Absent
  • 1+ Diminished or barely palpable
  • 2+ Expected
  • 3+ Increased
  • 4+ Bounding pulse

 Palpated jaw

1 of 1 point

 

Observations (1/1 point)

  •  No palpable abnormal findings
  •  Limited range of motion
  •  Popping or clicking

 Palpated lymph nodes

1 of 1 point

 

Head And Neck (1/3 point) Shadow Health HEENT Focused Exam Transcript

  •  No palpable nodes
  •  Palpable nodes on right side
  •  Palpable nodes on left side

Supraclavicular (1/3 point)

  • No palpable nodes
  • Palpable nodes on right side
  • Palpable nodes on left side

Axillary (1/3 point)

  •  No palpable nodes
  •  Palpable nodes on right side
  •  Palpable nodes on left side

 Palpated thyroid gland

1 of 1 point

 

Observations (1/2 point)

  •  No palpable abnormal findings
  •  Nodules
  •  Enlarged
  •  Irregular

Tenderness (1/2 point)

  • None reported
  • Tenderness reported

 Auscultated breath sounds

0.67 of 1 point

 

Breath Sounds (No point)

  •  Present in all areas
  •  Diminished in some areas
  •  Absent in some areas

Adventitious Sounds (1/3 point)

  • No adventitious sounds
  • Wheezing
  • Fine crackles
  • Stridor
  • Rhonchi
  • Rales

Location (1/3 point)

  •  All areas clear
  •  Adventitious sounds in anterior right upper lobe
  •  Adventitious sounds in anterior right middle lobe
  •  Adventitious sounds in anterior right lower lobe
  •  Adventitious sounds in anterior left upper lobe
  •  Adventitious sounds in anterior left lower lobe
  •  Adventitious sounds in posterior right upper lobe
  •  Adventitious sounds in posterior right lower lobe
  •  Adventitious sounds in posterior left upper lobe
  •  Adventitious sounds in posterior left lower lobe

 Auscultated temporal arteries

1 of 1 point

 

Right (1/2 point)

  •  No bruit
  •  Bruit

Left (1/2 point)

  • No bruit
  • Bruit

 Auscultated carotid arteries

1 of 1 point

 

Right (1/2 point)

  •  No bruit
  •  Bruit

Left (1/2 point)

  • No bruit
  • Bruit

 Tested pupillary reaction

1 of 1 point

 

Observations With Penlight (1/1 point) Shadow Health HEENT Focused Exam Transcript

  •  No visible abnormal findings (PERRL)
  •  Unequal
  •  Irregular
  •  Miosis
  •  Mydriasis
  •  Non-reactive to light

 Tested extraocular eye movements

1 of 1 point

 

Cardinal Fields (1/2 point)

  •  No visible abnormal findings
  •  Nystagmus
  •  Fixed pupil

Convergence (1/2 point)

  • No visible abnormal findings
  • Unequal bilaterally
  • Fixed pupil

 Tested peripheral vision

1 of 1 point

 

Observations (1/1 point)

  •  No abnormal findings
  •  Reduced right visual field
  •  Reduced left visual field

 Examined fundus with ophthalmoscope

1 of 1 point

 

Right: Retina (1/4 point)

  •  No visible abnormal findings
  •  Myelinated nerve fibers
  •  Papilledema
  •  Glaucomatous cupping
  •  Drusen bodies
  •  Cotton wool bodies
  •  Hemorrhage

Right: Disc Margin (1/4 point)

  • Sharp
  • Blurred

Left: Retina (1/4 point)

  •  No visible abnormal findings
  •  Myelinated nerve fibers
  •  Papilledema
  •  Glaucomatous cupping
  •  Drusen bodies
  •  Cotton wool bodies
  •  Hemorrhage

Left: Disc Margin (1/4 point)

  • Sharp
  • Blurred

 Tested visual acuity

1 of 1 point

 

Right (1/2 point)

  •  20/100
  •  20/70
  •  20/50
  •  20/40
  •  20/30
  •  20/25
  •  20/20
  •  20/15
  •  20/13
  •  20/10

Left (1/2 point)

  • 20/100
  • 20/70
  • 20/50
  • 20/40
  • 20/30
  • 20/25
  • 20/20
  • 20/15
  • 20/13
  • 20/10

 Performed Weber test

1 of 1 point

 

Results (1/1 point)

  •  Normal
  •  Conductive or sensorineural loss

 Performed Rinne test

1 of 1 point

 

Right (1/2 point)

  •  Normal
  •  Conductive loss

Left (1/2 point)

  • Normal
  • Conductive loss

 Performed whisper test

1 of 1 point

 

Right (1/2 point)

  •  Normal
  •  Unable to hear whispered words

Left (1/2 point)

  • Normal
  • Unable to hear whispered words

 Tested gag reflex

1 of 1 point

 

Observations (1/1 point)

  •  Intact
  •  Absent
  •  Hypersensitive

Empathy/Education

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity. Shadow Health HEENT Focused Exam Transcript

  • Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
  • Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
  • Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient

 1 Symptoms

Followed Up

 

 Description: Tina describes the symptoms that have been bothering her.
What brings you in today Question
03:36 AM CST
My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
I’m sorry these symptoms are causing you distress Empathize
03:37 AM CST
Thanks for saying that.
Have you been experiencing any other symptoms Question
03:37 AM CST
Let’s see… I have a lot going on so here’s the laundry list: sore and itchy throat, runny nose, itchy eyes.
How long have these symptoms been going on Question
03:38 AM CST
Like a week ago, everything started. Sore, itchy throat, runny nose.
When did your eyes start itching Question
03:39 AM CST
They’ve been itchy all week.
Tell me more about your throat pain Question
03:39 AM CST
It’s really sore, and it itches a lot, like in the back. Shadow Health HEENT Focused Exam Transcript
And the pain constant Question
03:39 AM CST
Yeah, it’s sore pretty much all the time.
When does your sore throat feel the worst Question
03:40 AM CST
It’s a little worse in the morning, but that’s really the only pattern I’ve noticed.
A scale of 0 to 10 how bad is your throat pain Question
03:40 AM CST
It’s like a 4 out of 10, maybe.
I’m sorry you are experiencing pain Empathize
03:40 AM CST
Thanks.
Do you experience seasonal allergies (Clarified to: do you have seasonal allergies) Question
04:02 AM CST
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 seasonal allergies)
Have you experienced any changes in your weight Question
04:03 AM CST
No, I think my weight is about the same.
I’ve got a fever recently Question
04:03 AM CST
No, I haven’t felt feverish at all this week. That’s another reason why this seems more like allergies than a cold.
you are correct to think that. typically a fever is present when someone has a cold Educate
04:04 AM CST
Alright, thanks for letting me know.
it is possible to develop new allergies as an adult Educate
04:04 AM CST
Thanks for telling me.
 Model Statement: “I’m sorry to hear you don’t feel well. I’ll ask you some questions to learn more about your symptoms, and we will make a plan to help you feel better.”

 2 Cause of Symptoms

Followed Up

 

 Description: Tina describes her symptoms as being similar to allergies.
Do you experience seasonal allergies (Clarified to: do you have seasonal allergies) Question
04:02 AM CST
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 seasonal allergies)
Have you experienced any changes in your weight Question
04:03 AM CST
No, I think my weight is about the same.
I’ve got a fever recently Question
04:03 AM CST
No, I haven’t felt feverish at all this week. That’s another reason why this seems more like allergies than a cold.
you are correct to think that. typically a fever is present when someone has a cold Educate
04:04 AM CST
Alright, thanks for letting me know.
it is possible to develop new allergies as an adult Educate
04:04 AM CST
Thanks for telling me.
 Model Statement: “It is possible to develop new allergies as an adult, and so I will take that into consideration as I try to determine the cause of your symptoms.” Shadow Health HEENT Focused Exam Transcript

 3 Medications

Not Followed Up

 

 Description: Tina describes her medication regimen.
Do taking medication (Clarified to: do you take medications) Question
03:56 AM CST
I’ve been using throat drops, like lozenges, for my sore throat. Other than that, I just have my inhaler. (Clarified to: if I take medications)
What do you use your inhaler for Question
03:56 AM CST
Oh, I got winded or something. I can’t really remember. I just felt a little short of breath so I used my inhaler to help out. It was just that one time.
When was the last time you used your inhaler Question
03:57 AM CST
Oh, last week probably.
What is the name of the inhaler you’re currently Question
03:57 AM CST
It’s just a regular Proventil inhaler.
How many puffs of your inhaler do you use Question
03:57 AM CST
If I use it, I do 2 or 3 puffs.
how many puffs of your inhaler you’re supposed to do Question
03:58 AM CST
I think it says to do 2 puffs. Shadow Health HEENT Focused Exam Transcript
Have you use anything to help treat your eye itchiness Question
03:59 AM CST
No, I haven’t done anything to try to make my eyes less itchy.
Have you taken any medication to help your runny nose Question
03:59 AM CST
No, I haven’t taken anything. Most of the stuff you get over-the-counter dries me out too much.
To take any medication like antihistamines to help your symptoms (Clarified to: did you take any allergy medication ) Question
03:59 AM CST
I haven’t taken anything yet. I wanted to make sure it was allergies first. (Clarified to: if I took allergy medication) Shadow Health HEENT Focused Exam Transcript
Do the lozenges help your sore throat that you take Question
04:01 AM CST
Yeah, both throat drops and water help a little bit.
How often do you take lozenges Question
04:01 AM CST
Maybe every few hours.
Are you allergic to any medication Question
04:02 AM CST
Yeah, I’m allergic to penicillin.
 Model Statement: “Thank you for letting me know that you’re using throat drops in addition to the medications you usually take. I will ask you a few questions about how you’re using each medication.”

 4 Headaches

Not Followed Up

 

 Description: Tina reports occasional headaches.
Do you have any troubles with your head (Clarified to: have you ever had any problems with your head?) Question
04:06 AM CST
Just like in general? I get headaches sometimes. (Clarified to: if I have had head problems)
Do you have a headache right now Question
04:06 AM CST
No, I don’t have a headache or anything right now.
An experienced head injury recently (Clarified to: have you ever had a head injury) Question
04:07 AM CST
No, I’ve never had any kind of head injury. (Clarified to: if I have had a head injury)
 Model Statement: “It sounds like you’re getting frequent headaches. I’m sorry you have to deal with those. I think we can determine more about what’s causing them, and try to relieve those for you.”

 5 Vision

Not Followed Up

 

 Description: Tina describes her vision problems and lack of eye care.
Have you any trouble with your eyes Question
04:09 AM CST
You mean, other than this itchy-eye stuff going on right now? I guess… my eyes get blurry sometimes when I read. It seems like my vision is getting worse over the years.
Are you experiencing any eye pain Question
04:09 AM CST
 Model Statement: “Blurry vision can be a frustrating symptom. Taking steps toward better eye care, like seeing an eye doctor, could improve your vision and prevent blurriness when you read.” Shadow Health HEENT Focused Exam Transcript

Documentation

Student Documentation Model Documentation
Subjective HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of sore, itchy throat, itchy eyes, and runny nose for the last week. She states that these symptoms started spontaneously and have been constant in nature. She does not note any specific aggravating symptoms, but states that her throat pain seems to be worse in the morning. She rates her throat pain as 4/10 and her throat itchiness as 5/10. She has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that she has some soreness when swallowing, but otherwise no other associated symptoms. She states that her nose “runs all day” and is clear discharge. She has not attempted any treatment for her nasal symptoms. She states that her eyes are constantly itchy and she has not attempted any eye specific treatment. She denies cough and recent illness. She has had no exposures to sick individuals. She denies changes in her hearing, vision, and taste. She denies fevers, chills, and night sweats. She has never been diagnosed with seasonal allergies, but does note that her sister has “hay fever”. Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history of trauma or headaches. • Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching prior to this past week. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea prior to this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth. No sore throat prior to this episode. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week.
Objective General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Rinne, Weber, and Whisper tests normal bilaterally. • Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain with palpation of frontal or maxillary sinuses. • Mouth/Throat: Moist buccal mucosa, no wounds visualized. Adequate dental hygiene. Uvula midline. Tonsils 1+ and without evidence of inflammation. Posterior pharynx is slightly erythematous with mild cobblestoning. •Neck: No cervical, infraclavicular lymphadenopathy. Thyroid is smooth without nodules or goiter. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation without wheezes, crackles, or cough. Shadow Health HEENT Focused Exam Transcript
Assessment Allergic Rhinitis
Plan Encourage Ms. Jones to continue to monitor symptoms and log her episodes of allergic symptoms with associated factors and bring log to next visit. • Initiate trial of loratadine (Claritin) 10 mg by mouth daily. • Encourage to increase intake of water and other fluids and educate on frequent handwashing. • Educate on avoidance of triggers and known allergens • Educate Ms. Jones on when to seek care including episodes of uncontrollable epistaxis, worsening headache, or fever. • Revisit clinic in 2-4 weeks for follow up and evaluation. Shadow Health HEENT Focused Exam Transcript