HEENT Transcript.pdf - HEENT Results | Turned In Advanced...

Unformatted text preview: HEENT Results | Turned In Advanced Health Assessment - Fall 2019, NGR 5035 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: Oct 12, 2019 | Patient Exam Time: 427 min All Lines (218) Interview Questions (79) Statements (25) Exam Actions (114) Objective Data Collection Education & Empathy Hello, my name is Patricia. I am the nurse Practioner Documentation Greet 10/12/19 1:46 PM EDT Hey. Can you verify your name and date of birth? Question 10/12/19 1:47 PM EDT My name's Tina Jones, and my birthday's February 17th. What brings you here today? Question 10/12/19 1:52 PM EDT My throat has been sore... and itchy. And my nose won't stop running. These symptoms are driving me nuts. This sounds like a challenging time for you. I understand your frustration at having your life interrupted by your illness symptoms Empathize 10/12/19 1:54 PM EDT I appreciate you saying that. How severe is your pain? Question 10/12/19 1:56 PM EDT It's not... terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won't go away. From 0 to 10 pain scale, being 0 no pain and 10 up most pain how do you rate your pain? (Clarified to Can you rate your current pain level on a scale of 0 to 10?.) Question 10/12/19 1:58 PM EDT It's like a 4 out of 10, maybe. (Clarified to how I would rate my pain on a scale.) Can you please describe your pain? Question 10/12/19 1:58 PM EDT It's really sore, and it itches a lot, like in the back. When did the pain start? Question 10/12/19 1:59 PM EDT It started a week ago. How has the pain change overtime? Question 10/12/19 1:59 PM EDT It hasn't really changed. It's been like this for a week -- it hurts worse in the morning but it's kind of always there. Have you been using any medication for pain? Question 10/12/19 2:01 PM EDT Yeah. Tylenol for headaches, Advil for cramps, and I've got my inhaler. Plus, I've been using lozenges for my throat. [AUDIO COMING SOON] How many lozenges did you take daily? Question 10/12/19 2:01 PM EDT I take them every few hours, so probably like... five or six a day. Did you have fever? No, I haven't felt feverish at all this week. That's another reason why this seems more like allergies than a cold. Question 10/12/19 2:02 PM EDT Do you have ye itchy? (Clarified to Are your eyes usually itchy?.) Question 10/12/19 2:03 PM EDT My eyes aren't usually like this. The only other time this happens is around cats. (Clarified to if my eyes are usually itchy.) You should avoid contact with cat to prevent allergies flare up Empathize 10/12/19 2:04 PM EDT Thanks for saying that. Do you have swallowing problems? Question 10/12/19 2:05 PM EDT Yes, it hurts my throat to swallow. what makes your sore throat worse? Question 10/12/19 2:06 PM EDT Well, my throat's usually worse in the mornings, and swallowing can make it sore, too. [AUDIO COMING SOON] Is your pain constant? Question 10/12/19 2:07 PM EDT Yeah, it's sore pretty much all the time. Are you taking any other over the counter medications? Question 10/12/19 2:08 PM EDT I've been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often. What kind of throat drops? Question 10/12/19 2:08 PM EDT They're like the generic version of Hall's or something like that. The drops relieve your pain Yeah, both throat drops and water help a little bit. Question 10/12/19 2:08 PM EDT how often do you use the drops? Question 10/12/19 2:09 PM EDT Maybe every few hours. how often do you feel runny nose? Question 10/12/19 2:10 PM EDT It runs all day. Are you taking any medication for runny nose? (Clarified to Do you take anything for your runny nose?.) Question 10/12/19 2:11 PM EDT No. (Clarified to if I am taking anything for my nose.) Any thing relieve your runny nose Question 10/12/19 2:11 PM EDT I haven't taken anything. Most of the stuff you get over-the-counter dries me out too much. Sorry to heard that, runny nose is very unconfortable Empathize 10/12/19 2:12 PM EDT Thanks for understanding. can you describe the nasal discharge Question 10/12/19 2:13 PM EDT I have a really runny nose. Everything coming out of it is really drippy and clear. It's gross. [AUDIO COMING SOON] do you have nasal itchy? No, I don't think so. Have you had asthma exacerbation? Question 10/12/19 2:14 PM EDT Question 10/12/19 2:14 PM EDT No, I haven't had a real asthma attack since I was a teenager. Good to heard that. That mean that you have a controlled asthma Empathize 10/12/19 2:15 PM EDT I appreciate you telling me that. Can you tell me what medications are you taking? Question 10/12/19 2:16 PM EDT I've been taking throat drops. And I have an inhaler, too. Any other over the counter medication? Question 10/12/19 2:17 PM EDT I've been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often. Are you taking medication for diabetes? Question 10/12/19 2:17 PM EDT I don't take anything for my diabetes anymore. Sorry to heard that. You need to maintain your diabetes under control Empathize 10/12/19 2:20 PM EDT Thanks. Take diabetes medication in a daily bases, performing at least 30 minutes of physical activity 5 days a week and follow a healthy an proper diet are the keys to control diabetes Educate 10/12/19 2:22 PM EDT OK, I understand. Do you use the inhaler every day? I don't use it every day. I used it last week, I think. Question 10/12/19 2:22 PM EDT What inhaler do you use? Educate 10/12/19 2:23 PM EDT Alright, thanks for letting me know. what is the name of inhaler? Question 10/12/19 2:23 PM EDT It's just a regular Proventil inhaler. Remember that you can use the proventil 2 puff inhaled every 4 to 6 hours or 1 puff inhaled every 4 hours as needed Educate 10/12/19 2:26 PM EDT Sure, I think I understand what you mean. To treat your diabetes I am going to prescribe Metformin 500 mg twice a day . You should take Metformin with breakfast and dinner. (No matching questions found.) Question 10/12/19 2:28 PM EDT To treat your diabetes I am going to prescribe Metformin 500 mg twice a day. You should take Metformin with breakfast and dinner. Educate 10/12/19 2:28 PM EDT That makes sense. Metformin is the best medication for you at this time. I hope you start the treatment immediately. Empathize 10/12/19 2:30 PM EDT I appreciate you saying that. I will order some laboratories test for now before start taking Metformin. I also will check your sugar levels every 3 month. I will refer you to a Nutritionist to help you with your diet Educate 10/12/19 2:33 PM EDT Thanks for telling me. describe you cats' allergic reaction (Clarified to What happens when you are around a cat?.) Question 10/12/19 2:35 PM EDT Oh, cats do all kinds of stuff -- first I sneeze and my nose runs, and if I'm exposed for too long, I can start to wheeze. (Clarified to what the symptoms of my cat allergy are.) Have you been in contact with cats recently? Question 10/12/19 2:35 PM EDT I was around cats like, a month ago at my cousin's house. I was wheezing a little bit then. Can you confirm if you have any other allergies? (Clarified to Are you allergic to anything else?.) Question 10/12/19 2:36 PM EDT Well, besides cats, I'm allergic to penicillin. (Clarified to if I have other allergies.) What is your reaction to penicillin? Question 10/12/19 2:36 PM EDT 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. Do you have any food allergies? Question 10/12/19 2:37 PM EDT Nope, no food allergies that I know of. Do you have any environmental allergies? Question 10/12/19 2:37 PM EDT Well, no. I mean, I never had allergies to pollen or anything outdoors like that. . . But my nose is acting just like my sister's right now, and she's always had hay fever. I'm starting to think that this is allergies. Do you have any seasonal allergies? Question 10/12/19 2:38 PM EDT Well, no. I mean, I never had allergies to pollen or anything outdoors like that. . . But my nose is acting just like my sister's right now, and she's always had hay fever. I'm starting to think that this is allergies. Can you tell me abut family allergies (No matching questions found.) Can you tell me about family allergies (No matching questions found.) Question 10/12/19 2:39 PM EDT Question 10/12/19 2:40 PM EDT Any allergies in your family members Question 10/12/19 2:40 PM EDT Yeah, my sister gets hay fever, so every spring she sneezes and her nose runs. She has to take something over-the-counter for it. What is your access to health care? Question 10/12/19 2:41 PM EDT I have health insurance through my job, so I can go to the doctor if I need to. It's always a hassle though, so I try to avoid it unless I really have to like right now. Do you have trouble affording health care? Question 10/12/19 2:42 PM EDT I'm in an OK place financially . . . without vision or dental insurance it's kind of tough, but my insurance covers most of my doctor's visits. [AUDIO COMING SOON] great to heard that Empathize 10/12/19 2:42 PM EDT Thanks. Visit your primary health care provider is very important for preventive care Educate 10/12/19 2:44 PM EDT That makes sense. Do you have trouble affording medications? Question 10/12/19 2:44 PM EDT I don't have problems affording medication. I think my insurance covers most of it . . . back when I was on metformin it was only about $10 a month. I just stopped taking it because I got sick of the side effects. [AUDIO COMING SOON] The most common side effect of Metformin is gastrointestinal upset, this mean nauseas, and some diarrhea. Take medication with food help to avoid the metformin side effects. Also, after 2 to 3 weeks of treatment, adverse effects dissapear Educate 10/12/19 2:46 PM EDT OK, I understand. Do you use glasses? Empathize 10/12/19 2:49 PM EDT Thanks for understanding. Have you had any vision problem? Question 10/12/19 2:49 PM EDT Yeah, maybe so. I've noticed my vision getting sort of blurry when I read. It seems like it's getting a little worse -- I notice it more. Dp you use glasses? (Clarified to Do you wear glasses?.) Question 10/12/19 2:49 PM EDT No, I don't wear glasses -- or contacts. (Clarified to if I wear glasses.) Did you check your vision with an specialist? Question 10/12/19 2:50 PM EDT I don't have vision insurance right now. At least, I don't think so . . . I haven't really checked. [AUDIO COMING SOON] I will refer you to the Ophthalmologist for you annual diabetic eye check up Educate 10/12/19 2:51 PM EDT Sure, I think I understand what you mean. It is very important to visit Ophthalmologist annually as preventive care for Diabetic patient. Empathize 10/12/19 2:53 PM EDT Thanks for saying that. Do you have ears problems? No, my ears are fine right now. do you use corrective lenses? Question 10/12/19 2:57 PM EDT Question 10/12/19 2:58 PM EDT No, I've never had glasses or contacts. when do you have blurry vision? Question 10/12/19 2:59 PM EDT Usually when I'm reading. does your headache and blurred vision occur at the same time? Question 10/12/19 3:00 PM EDT Well, I get them when I'm reading a lot, and I usually have some problems with blurry vision, too. If I read too much, I mean. I think you need to visit a optometrist to check near and far vision Empathize 10/12/19 3:01 PM EDT I appreciate you telling me that. Corrective lenses could be the solution for your eyes complaint Educate 10/12/19 3:02 PM EDT Thanks for telling me. You said that you do not have ear complaint, These mean that you do not have ear pain, or discharge Empathize 10/12/19 3:03 PM EDT I appreciate you saying that. Do you have hearing problems? Question 10/12/19 3:04 PM EDT No. Do you have nose bleeding? No. Question 10/12/19 3:04 PM EDT Do you have nose pain? Question 10/12/19 3:04 PM EDT The inside doesn't hurt, but it hurts on the outside -- It's raw from blowing it so much. Do you have smell problem? Question 10/12/19 3:05 PM EDT Um, I can't smell quite as well as usual. But I can still smell. Do you have any mouth pain? Question 10/12/19 3:05 PM EDT No, my mouth is okay. Do you have a problem in the tongue? Question 10/12/19 3:06 PM EDT No, my tongue is fine. How about your taste? (Clarified to How is your taste?.) Question 10/12/19 3:06 PM EDT I think I can taste everything pretty well. (Clarified to how my taste is.) Do you have dry mouth? Question 10/12/19 3:06 PM EDT No. Did you visit the Dentist recently? Um, I think the last time was a few years ago. I went twice a year as a kid, though. Do you have any teeth pain? Question 10/12/19 3:07 PM EDT Question 10/12/19 3:07 PM EDT No, I've got good teeth. They don't give me any problems. You should visit the dentist for annual check up and you should have a dental prophylaxis at least twice a year. Educate 10/12/19 3:09 PM EDT Alright, thanks for letting me know. Gingivitis is a complication from Diabetes. Control Diabetes avoid many complications Educate 10/12/19 3:10 PM EDT Thanks for telling me. Remember visit the dentist regularly Empathize 10/12/19 3:11 PM EDT Thanks for saying that. Have you had any surgery? Educate 10/12/19 3:12 PM EDT Alright, thanks for letting me know. Do you have any head injury? Question 10/12/19 3:13 PM EDT No, I've never had any kind of head injury. Did you have any eye injury? Question 10/12/19 3:13 PM EDT No, I don't think so. Did you have any ear injury? (Clarified to Have you had ear trauma?.) Question 10/12/19 3:13 PM EDT No, I've never had any major problems with my ears. (Clarified to if I have had ear trauma.) Do you feel lightheadedness? Question 10/12/19 3:14 PM EDT No, I don't ever get light-headed. Do you have any voice changes? Question 10/12/19 3:15 PM EDT No, my voice is fine. Same as usual. Do you have history of lymph nodes problems? Question 10/12/19 3:15 PM EDT I think my lymph nodes are fine. do you have eye watery discharge? (Clarified to Have you had eye discharge?.) Question 10/12/19 3:23 PM EDT Well, they've been watery. (Clarified to if I have had eye discharge.) Is the discharge clear? (Clarified to What color is the discharge?.) Question 10/12/19 3:23 PM EDT It's just clear. (Clarified to what color the discharge is.) Inspected general face Exam Action 10/12/19 3:38 PM EDT Inspected forehead and scalp Exam Action 10/12/19 3:38 PM EDT Inspected nose and mouth Exam Action 10/12/19 3:39 PM EDT Inspected right side of face Exam Action 10/12/19 3:39 PM EDT Inspected back of head Exam Action 10/12/19 3:39 PM EDT Inspected left side of face Exam Action 10/12/19 3:39 PM EDT Inspected general face Exam Action 10/12/19 3:39 PM EDT Performed otoscopic examination of right naris Exam Action 10/12/19 3:42 PM EDT Inspected right orbital area and sclera Exam Action 10/12/19 3:43 PM EDT Inspected left orbital area and sclera Exam Action 10/12/19 3:43 PM EDT Performed otoscopic examination of right naris Exam Action 10/12/19 3:43 PM EDT Performed otoscopic examination of left naris Exam Action 10/12/19 3:43 PM EDT Performed otoscopic examination of right ear Exam Action 10/12/19 3:44 PM EDT Performed otoscopic examination of left ear Exam Action 10/12/19 3:45 PM EDT Inspected mouth Exam Action 10/12/19 3:46 PM EDT Inspected mouth: pushed tongue left with tongue blade Exam Action 10/12/19 3:46 PM EDT Inspect mouth: pushed tongue right with tongue blade Exam Action 10/12/19 3:46 PM EDT Inspect mouth: lifted tongue with tongue blade Exam Action 10/12/19 3:46 PM EDT Inspected mouth: depressed tongue with tongue blade Exam Action 10/12/19 3:46 PM EDT Inspected mouth Exam Action 10/12/19 4:15 PM EDT Inspected front of neck Exam Action 10/12/19 4:15 PM EDT Inspected right side of neck Exam Action 10/12/19 4:15 PM EDT Inspected back of neck Exam Action 10/12/19 4:15 PM EDT Inspected left side of neck Exam Action 10/12/19 4:15 PM EDT Inspected front of neck Exam Action 10/12/19 4:16 PM EDT Inspected right orbital area and sclera Exam Action 10/12/19 4:24 PM EDT Inspected left orbital area and sclera Exam Action 10/12/19 4:24 PM EDT Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported Palpated frontal sinuses: No tenderness reported Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported Palpated maxillary sinuses: No tenderness reported Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+ Exam Action 10/12/19 4:28 PM EDT Exam Action 10/12/19 4:28 PM EDT Exam Action 10/12/19 4:29 PM EDT Exam Action 10/12/19 4:29 PM EDT Exam Action 10/12/19 4:29 PM EDT Palpated left carotid artery: No thrill, 2+ Exam Action 10/12/19 4:29 PM EDT Palpated right carotid artery: No thrill, 2+ Exam Action 10/12/19 4:29 PM EDT Palpated jaw: Full range of motion, no popping or clicking Exam Action 10/12/19 4:31 PM EDT Palpated lymph nodes of head and neck: Not palpable Exam Action 10/12/19 4:31 PM EDT Palpated axillary lymph nodes: Not palpable Exam Action 10/12/19 4:31 PM EDT Palpated supraclavicular lymph nodes: Not palpable Exam Action 10/12/19 4:32 PM EDT Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported Exam Action 10/12/19 4:32 PM EDT Auscultated breath sounds in anterior right upper lobe Exam Action 10/12/19 4:33 PM EDT Auscultated breath sounds in anterior left upper lobe Exam Action 10/12/19 4:33 PM EDT Auscultated breath sounds in anterior right middle lobe Exam Action 10/12/19 4:33 PM EDT Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 10/12/19 4:33 PM EDT Auscultated breath sounds in anterior right lower lobe Exam Action 10/12/19 4:33 PM EDT Auscultated breath sounds in anterior left lower lobe Exam Action 10/12/19 4:33 PM EDT Auscultated right temporal pulse Exam Action 10/12/19 4:34 PM EDT Auscultated left temporal pulse Exam Action 10/12/19 4:34 PM EDT Auscultated right carotid pulse Exam Action 10/12/19 4:34 PM EDT Auscultated left carotid pulse Exam Action 10/12/19 4:34 PM EDT Tested right pupillary reaction with penlight Exam Action 10/12/19 4:35 PM EDT Tested left pupillary reaction with penlight Exam Action 10/12/19 4:35 PM EDT follow my finger with just your eyes Question 10/12/19 4:35 PM EDT Ok. Tested convergence to the center Exam Action 10/12/19 4:36 PM EDT Tested EOM to the upper center Exam Action 10/12/19 4:36 PM EDT Tested EOM to the lower center Exam Action 10/12/19 4:36 PM EDT Tested EOM to the upper left Exam Action 10/12/19 4:36 PM EDT Tested EOM to the lower right Exam Action 10/12/19 4:36 PM EDT Tested EOM to the lower center Exam Action 10/12/19 4:36 PM EDT Tested convergence to the center Exam Action 10/12/19 4:36 PM EDT Tested EOM to the lower left Exam Action 10/12/19 4:36 PM EDT Tested convergence to the center Exam Action 10/12/19 4:36 PM EDT Tested EOM to the upper right Exam Action 10/12/19 4:36 PM EDT Tested convergence to the center Exam Action 10/12/19 4:37 PM EDT Tested convergence to the center Exam Action 10/12/19 4:37 PM EDT Tested EOM to the upper center Exam Action 10/12/19 4:37 PM EDT Tested convergence to the center Exam Action 10/12/19 4:37 PM EDT Tested EOM to the lower center Exam Action 10/12/19 4:37 PM EDT Tested convergence to the center Exam Action 10/12/19 4:37 PM EDT Tested EOM to the upper left Exam Action 10/12/19 4:37 PM EDT Tested convergence to the center Exam Action 10/12/19 4:37 PM EDT Tested EOM to the lower right Exam Action 10/12/19 4:37 PM EDT Tested convergence to the center Exam Action 10/12/19 4:37 PM EDT Tested EOM to the upper right Exam Action 10/12/19 4:37 PM EDT Tested convergence to the center Exam Action 10/12/19 4:37 PM EDT Tested EOM to the lower left Exam Action 10/12/19 4:37 PM EDT tell me when you can no longer see my fingers Question 10/12/19 4:38 PM EDT Ok, I will. Tested peripheral vision Exam Action 10/12/19 4:38 PM EDT Now. Examined fundus of right eye with ophthalmoscope Exam Action 10/12/19 4:38 PM ...
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