Tina Jones HEENT Interview | Completed | Shadow Health...

Unformatted text preview: HEENT Results | Completed Advanced Health Assessment - Spring 2019, NSG516 Online Return to Assignment Your Results Overview Turn In Lab Pass Experience Overview Transcript Subjective Data Collection Patient: Tina Jones Student Performance Index 53.33 out of 58 Objective Data Collection Education & Empathy Documentation Student Survey Proficiency Level: Proficient Beginning Digital Clinical Experience Score 100% This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent. Developing Proficient Students rated as “proficient” demonstrate an entrylevel expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner. Subjective Data Collection Objective Data Collection 23.33 out of 25 28 out of 28 Education and Empathy 2 out of 5 Time 108 minutes total spent in assignment Interaction with patient 108 minutes Transcript Started: Jan 15, 2019 | Patient Exam Time: 108 min All Lines (198) Interview Questions (108) Statements (11) Exam Actions (79) Good morning, I am Juliana and I am a nurse practitioner candidate. I will interview and examine you today. Greet 01/15/19 8:21 AM EST Hey. What brings you in today, Tina? Question 01/15/19 8:21 AM EST My throat has been sore... and itchy. And my nose won't stop running. These symptoms are driving me nuts. I am sorry to hear you are not feeling well today. Let us see what we can do to help these symptoms improve. Empathize 01/15/19 8:22 AM EST I appreciate you saying that. How long have you had these symptoms? Question 01/15/19 8:22 AM EST 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. How long have you had a sore throat? Question 01/15/19 8:22 AM EST Like a week ago, everything started. Sore, itchy throat, runny nose. Have you ever had this problem before? (Clarified to Have you had these symptoms before?.) Question 01/15/19 8:23 AM EST 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 had these symptoms before.) How severe is your sore throat? It's not... terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won't go away. Question 01/15/19 8:23 AM EST Does the sore throat cause shortness of breath? (No matching questions found.) Is the sore throat constant? Question 01/15/19 8:24 AM EST Question 01/15/19 8:24 AM EST Yeah, it's sore pretty much all the time. Can you describe the pain? Question 01/15/19 8:24 AM EST I don't know how I would describe it, other than "sore." How would you rate the pain on a scale from 1 to 10? Question 01/15/19 8:25 AM EST It's like a 4 out of 10, maybe. Does the pain radiate? Question 01/15/19 8:26 AM EST No, it's just in my throat. What do you think is causing the sore throat? Question 01/15/19 8:26 AM EST At first I thought I was getting sick, or a cold or something, but now it doesn't seem like that. My throat hasn't gotten worse, but it's not going away either. Does anything make your throat feel better? Question 01/15/19 8:26 AM EST All I've done is suck on some throat drops. And I've been drinking more water, which helps. Does anything make the throat pain worse? (Clarified to Does anything make the pain worse?.) Question 01/15/19 8:27 AM EST It's a little worse in the morning, but that's really the only pattern I've noticed. (Clarified to if anything makes the pain worse.) Do you have any other symptoms associated with the sore throat? (No matching questions found.) Question 01/15/19 8:27 AM EST Do you have any nasal discharge Question 01/15/19 8:28 AM EST Yes, it won't stop running! Can you describe the nasal discharge? Question 01/15/19 8:28 AM EST It's just clear. Do you have any eye symptoms? (Clarified to Do you have eye problems?.) Question 01/15/19 8:28 AM EST 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. (Clarified to if I have eye problems.) Do you experience any shortness of breath? Question 01/15/19 8:29 AM EST No, I don't have any trouble breathing on a regular basis. How often do you have a runny nose? Question 01/15/19 8:29 AM EST It runs all day. Have you been exposed to any allergens? Not lately. Do you have a family history of throat problems? Question 01/15/19 8:30 AM EST Question 01/15/19 8:31 AM EST No. Do you take any over the counter medications? Question 01/15/19 8:31 AM EST I've been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often. How often do you get headaches? Question 01/15/19 8:31 AM EST Maybe once a week? I usually do a lot of my school work at once, so I'll study for like, 5 or 6 hours. I usually end up with a headache by the end of the night. How would you rate these headaches? Question 01/15/19 8:32 AM EST Not too bad. . . I'd say about 3. Or a 4 if I really push it. What helps your headaches? Question 01/15/19 8:32 AM EST I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON] Does anything make your headaches worse? Question 01/15/19 8:32 AM EST Usually they get worse if I don't stop studying. I try to take a break when they start most of the time, but if I have a test or something coming up, I just have to try and ignore it. How long have you had these headaches for? I'm not sure -- Maybe over the last year or so. Question 01/15/19 8:32 AM EST Do you take any herbal supplements? Question 01/15/19 8:33 AM EST No, I don't take anything herbal. Do you take any prescription medications? Question 01/15/19 8:33 AM EST Yeah, the only prescription I have is my inhaler, but I only use it when I need it. How often do you use your inhaler? Question 01/15/19 8:33 AM EST I don't use it every day -- maybe I use it 2 or 3 times a week. Sometimes not at all. Have you been diagnosed with asthma? Question 01/15/19 8:34 AM EST Yeah, though it's not as bad as it used to be when I was a kid. What is the name of the inhaler you use? Question 01/15/19 8:34 AM EST It's just a regular Proventil inhaler. Can you describe your asthma symptoms? Question 01/15/19 8:34 AM EST My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs. How do you manage your asthma? Question 01/15/19 8:35 AM EST I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Do you have allergies? Question 01/15/19 8:35 AM EST Yeah. I'm allergic to cats. And dust, too. What do you use to improve your eye symptoms? Question 01/15/19 8:35 AM EST All I've done is suck on some throat drops. And I've been drinking more water, which helps. Does anything help your itchy eyes? Question 01/15/19 8:36 AM EST No, I haven't done anything to try to make my eyes less itchy. Are you exposed to allergens at work? Question 01/15/19 8:36 AM EST No, I don't notice any symptoms getting worse at work. Have you had a sore throat like this before? (Clarified to Anyone around you with a sore throat?.) Question 01/15/19 8:37 AM EST No, not sick, but my sister's allergies are bugging her. (Clarified to if I have been around anyone who has a sore throat.) Do you have any other symptoms? Question 01/15/19 8:38 AM EST Let's see... I have a lot going on so here's the laundry list: sore and itchy throat, runny nose, itchy eyes. Have you been to the eye doctor recently? Question 01/15/19 8:39 AM EST No, I haven't been to an eye doctor since I was a kid. Do you have any ear aches? No, my ears don't hurt. Question 01/15/19 8:39 AM EST Do you have any problems with your mouth? Question 01/15/19 8:39 AM EST No. Do you have any problems with your teeth? Question 01/15/19 8:39 AM EST No, I've got good teeth. They don't give me any problems. How severe are your asthma symptoms? Question 01/15/19 8:40 AM EST My asthma has been pretty under control. I use my inhaler a few times a week and it helps. Have you ever been hospitalized? Question 01/15/19 8:41 AM EST I used to go to the hospital for asthma growing up, but I hadn't been in a while until about a month ago. . . I had to go to the ER for my foot. What happened to your foot? (Clarified to Tell me about what's going on with your foot?.) Question 01/15/19 8:41 AM EST My foot is doing great. It doesn't hurt at all, and the scrape is healed up. I'm glad that's all over with. (Clarified to what is wrong with my foot.) I am glad to hear your foot is much better. Empathize 01/15/19 8:42 AM EST Thanks for understanding. Do you have any other medical problems? I have diabetes and asthma, but I can't even deal with those today. Question 01/15/19 8:42 AM EST What medication you take for diabetes? (Clarified to What medication do you take for diabetes?.) Question 01/15/19 8:42 AM EST I don't take medicine for it anymore. (Clarified to what medication I take for diabetes.) Why dont you take medicine for diabetes anymore? Question 01/15/19 8:43 AM EST I just got sick of dealing with it! What medicine were you prescribed for diabetes? Question 01/15/19 8:43 AM EST It was Metformin. Tell me more about why you stopped taking metformin. Question 01/15/19 8:43 AM EST I just got sick of dealing with it! What do you mean you got sick of dealing with metformin? Question 01/15/19 8:43 AM EST I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. That is great to hear that you have been changing your eating habits to help control your blood sugars Empathize 01/15/19 8:44 AM EST I appreciate you telling me that. Diabetes can have many complications. Taking the medications as prescribed can prevent cardiovascular problems such as a stroke. It can also prevent problems with vision that result from uncontrolled diabetes. Educate 01/15/19 8:45 AM EST Sure, I think I understand what you mean. Did you talk to your doctor prior to stop metformin? Question 01/15/19 8:46 AM EST No, I just stopped taking it because I was sick of dealing with taking it everyday and feeling gassy all the time. Have you ever undergone any procedures like an x ray? (No matching questions found.) Question 01/15/19 8:46 AM EST Were you ever operated on? Question 01/15/19 8:47 AM EST Nope. No surgeries... I've been lucky. Have you had any childhood illnesses? Question 01/15/19 8:47 AM EST Well, I got the usual stuff, like chicken pox. . . and I had the asthma, too. Do you take any vitamins? Question 01/15/19 8:48 AM EST No, I don't take any vitamins. Do you take any non traditional medications? (No matching questions found.) Question 01/15/19 8:48 AM EST What side effects did you experience from metformin? Question 01/15/19 8:48 AM EST I felt sick and gassy all the time. It was really uncomfortable. It can be difficult sometimes to cope with the medication side effects. Thanks for saying that. Empathize 01/15/19 8:49 AM EST When you get side effects you cant tolerate, you should always tell your provider, so the medication can e adjusted. That way you would tolerate it better Educate 01/15/19 8:50 AM EST That makes sense. Also, its important to always keep me updated of any medications you use, including the over the counter medications, because medication can interact with each other and it can be toxic. Educate 01/15/19 8:51 AM EST Thanks for telling me. Have you experienced adverse reactions to medications? (No matching questions found.) Question 01/15/19 8:51 AM EST Do you have allergies to medications? Question 01/15/19 8:51 AM EST Yeah, I'm allergic to penicillin. Can you describe your penicillin reaction? Question 01/15/19 8:51 AM EST I don't remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that. How do you manage your dust allergy? (Clarified to How do you manage your allergies?.) Question 01/15/19 8:52 AM EST I really try to stay away from cats, but when I'm around them and my asthma acts up I use my inhaler. (Clarified to how I manage my allergies.) Do you have trouble breathing around cats? (Clarified to When do you have breathing problems?.) Question 01/15/19 8:52 AM EST Um, I use my inhaler 2 or maybe even 3 times a week. I haven't had to use it this week though. (Clarified to when I have breathing problems.) Do you have seasonal allergies? Question 01/15/19 8:53 AM EST Well, no. I mean, I never had allergies to pollen or anything outdoors like that. . . But my nose is acting just like my sister's right now, and she's always had hay fever. I'm starting to think that this is allergies. Do you have any food allergies? Question 01/15/19 8:53 AM EST Nope, no food allergies that I know of. Do you have environmental allergies? Question 01/15/19 8:53 AM EST 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. Are you allergic to latex? Question 01/15/19 8:53 AM EST Nope. Have you ever smoked cigarettes? Question 01/15/19 8:54 AM EST No, I've never smoked a cigarette in my life. Have you ever chewed tobacco? (Clarified to Do you chew tobacco?.) Question 01/15/19 8:54 AM EST Chewing tobacco? No, that's disgusting. (Clarified to if I use chewing tobacco.) Do you drink alcohol? Question 01/15/19 8:54 AM EST I do sometimes, yeah, when I go out with my friends. How often do you drink alcohol? Question 01/15/19 8:54 AM EST No more than once or twice a week, sometimes less. How much alcohol do you drink? Question 01/15/19 8:54 AM EST I only have a few drinks when I go out. How many drinks do you have when you go out? Question 01/15/19 8:55 AM EST Like, two or three drinks. If I have more than two or three drinks, I feel like hell the next day, so I stop at three. What type of alcohol do you drink? Question 01/15/19 8:55 AM EST I usually get rum and diet Coke. I don't know why that matters. Different drinks have different alcohol levels. Thats why I have asked that question. Educate 01/15/19 8:56 AM EST Alright, thanks for letting me know. How many drinks do you have per month? Question 01/15/19 8:56 AM EST Oh, I don't know. Let's see... I might go out every few weeks, so twice a month... and I maybe have 2 or 3 drinks at a time, so maybe 6 drinks a month. Even if I go out more than usual, no more than ten. How does drinking alcohol make you feel? Question 01/15/19 8:57 AM EST It's fun to go out for drinks with my friends, but it's not, like, a huge part of my life or anything. Do you use any recreational drugs? No. Question 01/15/19 8:57 AM EST Are you involved in a stable relationship? (No matching questions found.) Question 01/15/19 8:57 AM EST Are you in a stable relationship? (Clarified to Are you currently in a relationship?.) Question 01/15/19 8:57 AM EST Um, not right now. (Clarified to if I am in a relationship.) What is your family medical history? Question 01/15/19 8:58 AM EST My mom has some issues, and I think some of my grandparents did, too. What health issues does your mom have? Question 01/15/19 8:58 AM EST Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. What health issues does your grandmother have? (Clarified to What health issues does granny have?.) Question 01/15/19 8:59 AM EST Granny is my only grandparent who's still alive. . . she's my dad's mom. She's 82. She has high blood pressure and cholesterol, but otherwise she's doing pretty well. (Clarified to what health issues Granny has.) What health issues did your grandfather have? Question 01/15/19 8:59 AM EST Poppa had high cholesterol and high blood pressure. Grandpa Jones-my dad's dad--had both of those too, I think. I think he had diabetes too, but he died of colon cancer. I was really little when he died. What type of work do you do? I'm a supervisor at Mid-American Copy & Ship. I've been working there since high school, and I've just kept moving up. Thats great to hear you have been doing well at work. Way to go! Question 01/15/19 9:00 AM EST Empathize 01/15/19 9:00 AM EST Thanks. Have you had any fever? Question 01/15/19 9:01 AM EST No, I haven't felt feverish at all this week. That's another reason why this seems more like allergies than a cold. HAve you had any dizziness? Question 01/15/19 9:01 AM EST No, I can't remember the last time I got dizzy. Have you had any eye discharge? Question 01/15/19 9:01 AM EST Well, they've been watery. Since when do you have blurry vision? Question 01/15/19 9:02 AM EST Usually when I'm reading. When did the blurry vision start? Question 01/15/19 9:02 AM EST I'm not sure -- Maybe over the last year or so. Do you have a red eye? 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. Question 01/15/19 9:02 AM EST May I examine you? Question 01/15/19 9:03 AM EST Yeah, that's fine. Inspected general face Exam Action 01/15/19 9:03 AM EST Inspected forehead and scalp Exam Action 01/15/19 9:03 AM EST Inspected nose and mouth Exam Action 01/15/19 9:03 AM EST Inspected left side of face Exam Action 01/15/19 9:03 AM EST Inspected back of head Exam Action 01/15/19 9:03 AM EST Inspected right side of face Exam Action 01/15/19 9:03 AM EST Inspected general face Exam Action 01/15/19 9:03 AM EST Inspected right orbital area and sclera Exam Action 01/15/19 9:04 AM EST Inspected lower conjunctiva Exam Action 01/15/19 9:04 AM EST Inspected upper conjunctiva Exam Action 01/15/19 9:04 AM EST Inspected left orbital area and sclera Exam Action 01/15/19 9:04 AM EST Performed otoscopic examination of right naris Exam Action 01/15/19 9:05 AM EST Performed otoscopic examination of left naris Exam Action 01/15/19 9:05 AM EST Performed otoscopic examination of right naris Exam Action 01/15/19 9:05 AM EST Performed otoscopic examination of left naris Exam Action 01/15/19 9:05 AM EST Performed otoscopic examination of right ear Exam Action 01/15/19 9:06 AM EST Performed otoscopic examination of left ear Exam Action 01/15/19 9:06 AM EST Inspected mouth Exam Action 01/15/19 9:07 AM EST Inspected mouth: pushed tongue left with tongue blade Exam Action 01/15/19 9:08 AM EST Inspect mouth: pushed tongue right with tongue blade Exam Action 01/15/19 9:08 AM EST Inspect mouth: lifted tongue with tongue blade Exam Action 01/15/19 9:08 AM EST Inspected mouth: depressed tongue with tongue blade Exam Action 01/15/19 9:09 AM EST Inspected front of neck Exam Action 01/15/19 9:09 AM EST Inspected left side of neck Exam Action 01/15/19 9:09 AM EST Inspected back of neck Exam Action 01/15/19 9:09 AM EST Inspected right side of neck Exam Action 01/15/19 9:09 AM EST Inspected front of neck Exam Action 01/15/19 9:09 AM EST Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported Exam Action 01/15/19 9:10 AM EST Palpated frontal sinuses: No tenderness reported Exam Action 01/15/19 9:10 AM EST Palpated maxillary sinuses: No tenderness reported Exam Action 01/15/19 9:10 AM EST Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+ Exam Action 01/15/19 9:10 AM EST Palpated right carotid ar...
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