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 avatarHello. 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 JonesHey.
Your avatarMay I know your name, please?Question
05/29/20 6:31 PM EDT
Tina JonesTina Jones.
Your avatarWhat brings you to the Clinic today Tina?Question
05/29/20 6:31 PM EDT
Tina JonesMy throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
Your avatarAm sorry to hear thatEmpathize
05/29/20 6:32 PM EDT
Tina JonesI appreciate you telling me that.

Tina Jones HEENT shadow health assessment transcript
Your avatarHow long have you had these symptoms?Question
05/29/20 6:32 PM EDT
Tina JonesMy itchy eyes, runny nose, and sore throat all started a week ago. [AUDIO COMING SOON]
Your avatarHave you ever had these symptoms before?Question
05/29/20 6:33 PM EDT
Tina JonesNo.
Your avatarHow severe is your sore throat?Question
05/29/20 6:36 PM EDT
Tina JonesIt’s not… terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won’t go away.
Your avatarIs the sore throat constant?Question
05/29/20 6:36 PM EDT
Tina JonesYeah, it’s sore pretty much all the time.
Your avatarcan you describe the pain?Question
05/29/20 6:38 PM EDT
Tina JonesIt’s really sore, and it itches a lot, like in the back.
Your avatarhow would you rate the pain on a scale of 0 to 10?Question
05/29/20 6:38 PM EDT
Tina JonesIt’s like a 4 out of 10, maybe.
Your avatarDoes the pain radiate?Question
05/29/20 6:38 PM EDT
Tina JonesNo, it’s just in my throat.
Your avatarWhat do you think is causing the sore throat?Question
05/29/20 6:39 PM EDT
Tina JonesAt 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 avatarDoes anything make the throat feel better?Question
05/29/20 6:40 PM EDT
Tina JonesAll I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
Your avatarDoes anything make the pain worse?Question
05/29/20 6:41 PM EDT
Tina JonesIt’s a little worse in the morning, but that’s really the only pattern I’ve noticed.
Your avatarDo you have any other symptoms associated with the sore throat? (No matching questions found.)Question
05/29/20 6:43 PM EDT
Your avatardo you have any nasal discharge?Question
05/29/20 6:43 PM EDT
Tina JonesYes, it won’t stop running!
Your avatar
Tina Jones HEENT shadow health assessment transcript
Your avatarDo you take any over-the-counter medications?Question
05/29/20 6:50 PM EDT
Tina JonesI’ve been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often.
Your avatarHow often do you get headaches?Question
05/29/20 6:51 PM EDT
Tina JonesMaybe 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 avatarHow would you rate these headaches?Question
05/29/20 6:51 PM EDT
Tina JonesNot too bad. . . I’d say about 3. Or a 4 if I really push it.
Your avatarWhat helps your headache?Question
05/29/20 6:51 PM EDT
Tina JonesI just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON]
Your avatarDoes anything make your headaches worse?Question
05/29/20 6:52 PM EDT
Tina JonesUsually, 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 avatarHow long have you had these headaches?Question
05/29/20 6:52 PM EDT
Tina JonesI’m not sure — Maybe over the last year or so.
Your avatarDo you take any herbal supplements?Question
05/29/20 6:53 PM EDT
Tina JonesNo, I don’t take anything herbal.
Your avatarDo you take any prescription medications?Question
05/29/20 6:53 PM EDT
Tina Jones
Tina Jones HEENT shadow health assessment transcript
Your avatarDo you take vitamins?Question
05/29/20 7:21 PM EDT
Tina JonesNo, I don’t take any vitamins.
Your avatarAre your immunizations up to date?Question
05/29/20 7:22 PM EDT
Tina JonesI’m pretty sure I am, yeah.
Your avatarWhat side effects did you have with metformin?Question
05/29/20 7:23 PM EDT
Tina JonesI felt sick and gassy all the time. It was really uncomfortable.
Your avatarWhen you get side effects that you cannot tolerate, you should speak to your doctor for alternatives and also confirm if they react with other medicationsEducate
05/29/20 7:25 PM EDT
Tina JonesAlright, thanks for letting me know.
Your avatarAre you allergic to medications?Question
05/29/20 7:28 PM EDT
Tina JonesYeah, I’m allergic to penicillin.
Your avatarDo you have seasonal allergies?Question
05/29/20 7:28 PM EDT
Tina JonesWell, 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 avatarDo 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 JonesNope, no food allergies that I know of. (Clarified to if I have food allergies.)
Your avatarDo you smoke cigarettes?Question
05/29/20 7:32 PM EDT
Tina JonesNo, I’ve never smoked a cigarette in my life.
Your avatarDo you take alcohol? (No matching questions found.)Question
05/29/20 7:32 PM EDT
Your avatarDo you drink alcohol?Question
05/29/20 7:33 PM EDT
Tina JonesI do sometimes, yeah, when I go out with my friends.
Your avatarHow 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 JonesLike, 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 avatarThat’s moderate drinking which is ok.Educate
05/29/20 7:34 PM EDT
Tina JonesThanks for telling me.
Your avatarWhat type of alcohol do you take?Question
05/29/20 7:34 PM EDT
Tina JonesI usually get rum and diet coke. I don’t know why that matters.
Your avatarDifferent drinks have different alcohol levels, that’s why I asked.Educate
05/29/20 7:35 PM EDT
Tina JonesOK, I understand.
Your avatarHow is your family medical history?Question
05/29/20 7:35 PM EDT
Tina JonesMy mom has some issues, and I think some of my grandparents did, too.
Your avatarWhat health issues does your mother have?Question
05/29/20 7:35 PM EDT
Tina JonesMom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
Your avatarWhat medical issues does your father have? (Clarified to Tell me about your dad’s health?.)Question
05/29/20 7:36 PM EDT
Tina JonesHe passed last year. (Clarified to what health issues my dad has.)
Your avatarAm sorry to hear thatEmpathize
05/29/20 7:36 PM EDT
Tina JonesThanks for understanding.
Your avatardid your father have any medical conditions?Question
05/29/20 7:37 PM EDT
Tina JonesHe had high blood pressure and cholesterol, and diabetes too…the same kind as me.
Your avatarWhat health issues does your maternal grandmother have?Question
05/29/20 7:37 PM EDT
Tina JonesNana had high blood pressure and cholesterol, I think.

Tina Jones HEENT shadow health assessment transcript
Your avatarWhat issues does your maternal grandfather have?Question
05/29/20 7:38 PM EDT
Tina JonesPoppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
Your avatarWhat health issues does your paternal grandmother have?Question
05/29/20 7:38 PM EDT
Tina JonesGranny’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 avatarWhat health issues does your paternal grandfather have?Question
05/29/20 7:39 PM EDT
Tina JonesGrandpa 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 avatarhow did you cope with your father’s death?Question
05/29/20 7:39 PM EDT
Tina JonesWell, 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 avatarSeems you have a strong support system which is great.Empathize
05/29/20 7:40 PM EDT
Tina JonesThanks.
Your avatarWhat health conditions does your sister have?Question
05/29/20 7:41 PM EDT
Tina JonesShe’s pretty healthy. She has asthma too, but she almost never has attacks.
Your avatarwhat health conditions does your brother have?Question
05/29/20 7:41 PM EDT
Tina JonesNone that I know of. He’s got some extra weight on him, I guess.
Your avatarAnyone with an obesity problem in your family?Question
05/29/20 7:45 PM EDT
Tina JonesNo, 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 avatarAnyone with an alcoholism problem in the family?Question
05/29/20 7:46 PM EDT
Tina JonesOne person in the family, my dad’s brother, has an alcohol problem, but we never see him.
Your avatarWhat work do you do?Question
05/29/20 7:47 PM EDT
Tina JonesI’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up.
Your avatarAm happy to hear that your job is fine and you are doing wellEmpathize
05/29/20 7:47 PM EDT
Tina JonesThanks for understanding.
Your avatarWhat is your highest level of education?Question
05/29/20 7:48 PM EDT
Tina JonesWell, I’m finishing up my Bachelor’s degree right now.
Your avatarWhat is your Major?Question
05/29/20 7:48 PM EDT
Tina JonesI’m going to get my bachelor’s in accounting.
Your avatar
Tina Jones HEENT shadow health assessment transcript.
Tina JonesI 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 avatarAm sure when you get less busy, you will travel moreEmpathize
05/29/20 7:52 PM EDT
Tina JonesI appreciate you saying that.
Your avatarHave you been wheezing?Question
05/29/20 7:52 PM EDT
Tina JonesNo, I haven’t been wheezing this week.
Your avatarPlease let me examine you now. (No matching questions found.)Question
05/29/20 7:53 PM EDT
Your avatarPlease let me examine you now.Educate
05/29/20 7:53 PM EDT
Tina JonesSure, I think I understand what you mean.
Your avatarInspected general faceExam Action
05/29/20 7:57 PM EDT
Your avatarInspected forehead and scalpExam Action
05/29/20 7:58 PM EDT
Your avatarInspected nose and mouthExam Action
05/29/20 7:58 PM EDT
Your avatarInspected left side of the faceExam Action
05/29/20 7:58 PM EDT
Your avatarInspected back of the headExam Action
05/29/20 7:58 PM EDT
Your avatarInspected right side of the faceExam Action
05/29/20 7:58 PM EDT
Your avatarInspected general faceExam Action
05/29/20 7:58 PM EDT
Your avatarInspected right side of the faceExam Action
05/29/20 7:58 PM EDT
Your avatarInspected general faceExam Action
05/29/20 7:58 PM EDT
Your avatarInspected nose and mouthExam Action
05/29/20 7:58 PM EDT
Your avatarInspected forehead and scalpExam Action
05/29/20 7:58 PM EDT
Your avatarInspected nose and mouthExam Action
05/29/20 7:58 PM EDT
Your avatarInspected right orbital area and scleraExam Action
05/29/20 7:59 PM EDT
Your avatarInspected lower conjunctivaExam Action
05/29/20 7:59 PM EDT
Your avatarInspected upper conjunctivaExam Action
05/29/20 8:00 PM EDT
Your avatarInspected upper conjunctivaExam Action
05/29/20 8:00 PM EDT
Your avatarInspected left orbital area and scleraExam Action
05/29/20 8:00 PM EDT
Your avatarPerformed otoscopic examination of right narisExam Action
05/29/20 8:00 PM EDT
Your avatarPerformed otoscopic examination of left narisExam Action
05/29/20 8:01 PM EDT
Your avatarPerformed otoscopic examination of the right earExam Action
05/29/20 8:02 PM EDT
Your avatarPerformed otoscopic examination of left earExam Action
05/29/20 8:02 PM EDT
Your avatarInspected mouthExam Action
05/29/20 8:03 PM EDT
Your avatarInspected mouth: pushed tongue left with tongue bladeExam Action
05/29/20 8:04 PM EDT
Your avatarInspect mouth: pushed tongue right with tongue bladeExam Action
05/29/20 8:04 PM EDT
Your avatarInspect mouth: lifted tongue with tongue bladeExam Action
05/29/20 8:04 PM EDT
Your avatarInspected mouth: depressed tongue with tongue bladeExam Action
05/29/20 8:04 PM EDT
Your avatarInspected front of neckExam Action
05/29/20 8:06 PM EDT
Your avatarInspected left side of neckExam Action
05/29/20 8:06 PM EDT
Your avatarInspected back of neckExam Action
05/29/20 8:06 PM EDT
Your avatarInspected right side of neck


Tina Jones HEENT shadow health assessment transcript.
Exam Action
05/29/20 8:06 PM EDT
Your avatarInspected back of neckExam Action
05/29/20 8:06 PM EDT
Your avatarInspected right side of neckExam Action
05/29/20 8:07 PM EDT
Your avatarInspected front of neckExam Action
05/29/20 8:07 PM EDT
Your avatarInspected right side of neckExam Action
05/29/20 8:07 PM EDT
Your avatarInspected front of neckExam Action
05/29/20 8:07 PM EDT
Your avatarPalpated scalp: No balding or thinning hair distribution, no masses, no tenderness reportedExam Action
05/29/20 8:07 PM EDT
Your avatarPalpated maxillary sinuses: No tenderness reportedExam Action
05/29/20 8:08 PM EDT
Your avatarPalpated frontal sinuses: No tenderness reportedExam Action
05/29/20 8:08 PM EDT
Your avatarPalpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+Exam Action
05/29/20 8:08 PM EDT
Your avatarPalpated right carotid artery: No thrill, 2+Exam Action
05/29/20 8:10 PM EDT
Your avatarPalpated left carotid artery: No thrill, 2+Exam Action
05/29/20 8:10 PM EDT
Your avatarPalpated jaw: Full range of motion, no popping or clickingExam Action
05/29/20 8:11 PM EDT
Your avatarPalpated axillary lymph nodes: Not palpableExam Action
05/29/20 8:11 PM EDT
Your avatarPalpated supraclavicular lymph nodes: Not palpableExam Action
05/29/20 8:12 PM EDT
Your avatarPalpated lymph nodes of head and neck: Not palpableExam Action
05/29/20 8:12 PM EDT
Your avatarPalpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reportedExam Action
05/29/20 8:12 PM EDT
Your avatarAuscultated breath sounds in anterior right lower lobeExam Action
05/29/20 8:13 PM EDT
Your avatarAuscultated breath sounds in anterior right middle lobeExam Action
05/29/20 8:13 PM EDT
Your avatarAuscultated breath sounds in anterior right upper lobeExam Action
05/29/20 8:13 PM EDT
Your avatarAuscultated breath sounds in anterior left upper lobeExam Action
05/29/20 8:13 PM EDT
Your avatarAuscultated breath sounds in anterior left mid-chest (upper lobe)Exam Action
05/29/20 8:13 PM EDT
Your avatarAuscultated breath sounds in anterior left lower lobeExam Action
05/29/20 8:13 PM EDT
Your avatarAuscultated breath sounds in posterior left upper lobeExam Action
05/29/20 8:13 PM EDT
Your avatarAuscultated breath sounds in posterior left mid-back (lower lobe)Exam Action
05/29/20 8:13 PM EDT
Your avatarAuscultated breath sounds in posterior left lower lobeExam Action
05/29/20 8:13 PM EDT
Your avatarAuscultated breath sounds in posterior left lower lobe on sideExam Action
05/29/20 8:13 PM EDT
Your avatarAuscultated breath sounds in posterior left lower lobe near spineExam Action
05/29/20 8:13 PM EDT
Your avatarAuscultated breath sounds in posterior right lower lobe near spineExam Action
05/29/20 8:14 PM EDT
Your avatarAuscultated breath sounds in posterior right lower lobe on sideExam Action
05/29/20 8:14 PM EDT
Your avatarAuscultated breath sounds in posterior right lower lobeExam Action
05/29/20 8:14 PM EDT
Your avatarAuscultated breath sounds in posterior right mid-back (lower lobe)Exam Action
05/29/20 8:14 PM EDT
Your avatarAuscultated breath sounds in posterior right upper lobeExam Action
05/29/20 8:14 PM EDT
Your avatarAuscultated right temporal pulseExam Action
05/29/20 8:14 PM EDT
Your avatarAuscultated left temporal pulseExam Action
05/29/20 8:14 PM EDT
Your avatarAuscultated right carotid pulseExam Action
05/29/20 8:15 PM EDT
Your avatarAuscultated left carotid pulseExam Action
05/29/20 8:15 PM EDT
Your avatarTested left pupillary reaction with penlightExam Action
05/29/20 8:16 PM EDT
Your avatarTested right pupillary reaction with penlightExam Action
05/29/20 8:16 PM EDT
Your avatarFollow my finger with just your eyesQuestion
05/29/20 8:17 PM EDT
Tina JonesOk.
Your avatarTested EOM to the upper rightExam Action
05/29/20 8:17 PM EDT
Your avatarTested EOM to the lower rightExam Action
05/29/20 8:17 PM EDT
Your avatarTested EOM to the lower centerExam Action
05/29/20 8:17 PM EDT
Your avatarTested convergence to the centerExam Action
05/29/20 8:17 PM EDT
Your avatarTested EOM to the upper centerExam Action
05/29/20 8:17 PM EDT
Your avatarTested EOM to the upper leftExam Action
05/29/20 8:17 PM EDT
Your avatarTested EOM to the lower leftExam Action
05/29/20 8:17 PM EDT
Your avatarTell me when you can no loner seeQuestion
05/29/20 8:18 PM EDT
Tina JonesOk, I will.
Your avatarTested peripheral visionExam Action
05/29/20 8:18 PM EDT
Tina JonesNow.
Your avatarExamined fundus of right eye with ophthalmoscopeExam Action
05/29/20 8:20 PM EDT
Your avatarExamined fundus of left eye with ophthalmoscopeExam Action
05/29/20 8:21 PM EDT
Tina JonesF P
Your avatarIs the volume the same in both ears or louder in one earQuestion
05/29/20 8:24 PM EDT
Tina JonesOk.
Tina JonesSame in both ears.
Your avatarPerformed Weber test with tuning forkExam Action
05/29/20 8:25 PM EDT
Your avatarTell me when you no longer hear the ringingQuestion
05/29/20 8:25 PM EDT
Tina JonesOk, I will.
Tina JonesNow.
Your avatarF.Question
05/29/20 8:26 PM EDT
Tina JonesF.
Your avatarEightQuestion
05/29/20 8:26 PM EDT
Tina JonesEight.
Your avatarW.Question
05/29/20 8:26 PM EDT
Tina JonesW.
Your avatarPerformed whisper test in right earExam Action
05/29/20 8:26 PM EDT
Your avatarFourQuestion
05/29/20 8:26 PM EDT
Tina JonesFour.
Your avatarR.Question
05/29/20 8:26 PM EDT
Tina JonesR.
Your avatarNine.Question
05/29/20 8:26 PM EDT
Tina JonesNine.
Your avatarPerformed whisper test in left earExam Action
05/29/20 8:27 PM EDT
Your avatarTested gag reflex with tongue bladeExam Action
05/29/20 8:27 PM EDT
Tina Jones HEENT shadow health assessment transcript
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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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