Tina Jones HEENT Completed

Tina Jones HEENT

Experience Overview

Patient: Tina Jones

Digital Clinical Experience Score

98.2%

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.

Student Performance Index

out of

Proficiency Level:

Proficient

Students rated as “proficient” demonstrate an entry-level 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

out of

Objective Data Collection

out of

Education and Empathy

out of

Time

52 minutes total spent in assignment

Interaction with patient

52 minutes

Transcript

Started: Mar 27, 2025 | Total Time: 52 min

All Lines (130)Interview Questions (44)Statements (1)Exam Actions (85)

	Hello, my name is Mileidy. I will be your nurse today	Greet 03/27/25 4:31 AM EDT
	Hey.
	WHat brings you here today	Question 03/27/25 4:31 AM EDT
	My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
	I am sorry for that	Empathize 03/27/25 4:31 AM EDT
	I appreciate you saying that.
	When did the symptoms start	Question 03/27/25 4:32 AM EDT
	Like a week ago, everything started. Sore, itchy throat, runny nose.
	How severe us thr throat discomfort?	Question 03/27/25 4:32 AM 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.
	What is the frequency and duration of runny nose? (No matching questions found.)	Question 03/27/25 4:32 AM EDT
	What is the frequency of runny nose?	Question 03/27/25 4:33 AM EDT
	It runs all day.
	What nasal symptoms do you have?	Question 03/27/25 4:33 AM EDT
	It’s been running nonstop!
	What does the nasal discharge look like?	Question 03/27/25 4:43 AM EDT
	It’s just clear.
	Do you have eye symptoms?	Question 03/27/25 4:44 AM EDT
	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.
	Do you have any respiratory symptoms?	Question 03/27/25 4:44 AM EDT
	My breathing’s fine. I haven’t had any asthma problems come up.
	what do you think has caused the symptoms?	Question 03/27/25 4:45 AM EDT
	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.
	What relieves the symptoms?	Question 03/27/25 4:45 AM EDT
	All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
	What relieves the nose and eye symptoms	Question 03/27/25 4:46 AM EDT
	All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
	What are the relieving factors for nose and eye symptoms	Question 03/27/25 4:46 AM EDT
	All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
	What makes nose and eye symptoms better? (No matching questions found.)	Question 03/27/25 4:46 AM EDT
	What improves nose and eye symptoms? (No matching questions found.)	Question 03/27/25 4:47 AM EDT
	nose and eye symptoms?	Question 03/27/25 4:47 AM EDT
	Yes, my nose won’t stop running!
	What relieves nose and eye symptoms?	Question 03/27/25 4:47 AM EDT
	All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
	Do you use medications?	Question 03/27/25 4:48 AM EDT
	No, I haven’t done anything to try to make my eyes less itchy.
	Do you use an inhaler	Question 03/27/25 4:48 AM EDT
	Yeah, I use it when my asthma acts up.
	Are you exposed to allergens?	Question 03/27/25 4:48 AM EDT
	Not lately.
	How is your healthcare access	Question 03/27/25 4:49 AM 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 any head problem?	Question 03/27/25 4:49 AM EDT
	Just like in general? I get headaches sometimes.
	What causes the headaches?	Question 03/27/25 4:50 AM EDT
	When I get headaches, it’s usually just from reading. I only get them about once a week and it doesn’t really hurt on one side or the other. The pain is mostly behind both eyes.
	Do you have vision problems?	Question 03/27/25 4:50 AM 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.
	Do you have any ears problem	Question 03/27/25 4:50 AM EDT
	No, my ears are fine right now.
	Do you have any mouth or jaw problem?	Question 03/27/25 4:50 AM EDT
	No, that’s not where I’m having problems. [AUDIO COMING SOON]
	Do you have any dental issue?	Question 03/27/25 4:51 AM EDT
	No, I’ve got good teeth. They don’t give me any problems.
	Do you have any throat issue?	Question 03/30/25 6:54 PM EDT
	Yes, my throat’s sore right now.
	Are there any relevant family history? (Clarified to Can you tell me about your family medical history?.)	Question 03/30/25 6:55 PM EDT
	My mom has some issues, and I think some of my grandparents did, too. (Clarified to to tell you about my family medical history.)
	Are there any family health history related to your condition?	Question 03/30/25 6:55 PM EDT
	My mom has some issues, and I think some of my grandparents did, too.
	Do you have a family member with this issue? (Clarified to Do you have any family history of breathing problems?.)	Question 03/30/25 6:56 PM EDT
	My baby sister has asthma, too, but no one else in the family has lung problems, I don’t think. (Clarified to if my family has a history of breathing problems.)
	Do you have a family history of throat problems?	Question 03/30/25 6:57 PM EDT
	No.
	Inspected general face	Exam Action 03/30/25 7:19 PM EDT
	Inspected forehead and scalp	Exam Action 03/30/25 7:19 PM EDT
	Inspected nose and mouth	Exam Action 03/30/25 7:19 PM EDT
	Inspected right side of face	Exam Action 03/30/25 7:19 PM EDT
	Inspected back of head	Exam Action 03/30/25 7:19 PM EDT
	Inspected right side of face	Exam Action 03/30/25 7:19 PM EDT
	Inspected general face	Exam Action 03/30/25 7:19 PM EDT
	Inspected left side of face	Exam Action 03/30/25 7:19 PM EDT
	Inspected back of head	Exam Action 03/30/25 7:19 PM EDT
	Inspected left side of face	Exam Action 03/30/25 7:19 PM EDT
	Inspected general face	Exam Action 03/30/25 7:19 PM EDT
	Inspected right orbital area and sclera	Exam Action 03/30/25 7:19 PM EDT
	Inspected left orbital area and sclera	Exam Action 03/30/25 7:19 PM EDT
	Inspected lower conjunctiva	Exam Action 03/30/25 7:20 PM EDT
	Inspected upper conjunctiva	Exam Action 03/30/25 7:20 PM EDT
	Performed otoscopic examination of right naris	Exam Action 03/30/25 7:20 PM EDT
	Performed otoscopic examination of left naris	Exam Action 03/30/25 7:20 PM EDT
	Performed otoscopic examination of right naris	Exam Action 03/30/25 7:20 PM EDT
	Performed otoscopic examination of right ear	Exam Action 03/30/25 7:20 PM EDT
	Performed otoscopic examination of left ear	Exam Action 03/30/25 7:20 PM EDT
	Inspected mouth	Exam Action 03/30/25 7:20 PM EDT
	Inspected mouth: pushed tongue left with tongue blade	Exam Action 03/30/25 7:20 PM EDT
	Inspect mouth: pushed tongue right with tongue blade	Exam Action 03/30/25 7:20 PM EDT
	Inspect mouth: lifted tongue with tongue blade	Exam Action 03/30/25 7:20 PM EDT
	Inspected mouth: depressed tongue with tongue blade	Exam Action 03/30/25 7:20 PM EDT
	Inspected front of neck	Exam Action 03/30/25 7:20 PM EDT
	Inspected right side of neck	Exam Action 03/30/25 7:20 PM EDT
	Inspected back of neck	Exam Action 03/30/25 7:20 PM EDT
	Inspected left side of neck	Exam Action 03/30/25 7:20 PM EDT
	Inspected back of neck	Exam Action 03/30/25 7:20 PM EDT
	Inspected right side of neck	Exam Action 03/30/25 7:21 PM EDT
	Inspected front of neck	Exam Action 03/30/25 7:21 PM EDT
	Inspected left side of neck	Exam Action 03/30/25 7:21 PM EDT
	Inspected front of neck	Exam Action 03/30/25 7:21 PM EDT
	Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported	Exam Action 03/30/25 7:21 PM EDT
	Palpated frontal sinuses: No tenderness reported	Exam Action 03/30/25 7:21 PM EDT
	Palpated maxillary sinuses: No tenderness reported	Exam Action 03/30/25 7:21 PM EDT
	Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+	Exam Action 03/30/25 7:21 PM EDT
	Palpated right carotid artery: No thrill, 2+	Exam Action 03/30/25 7:21 PM EDT
	Palpated left carotid artery: No thrill, 2+	Exam Action 03/30/25 7:22 PM EDT
	open and close your mouth	Question 03/30/25 7:22 PM EDT
	Palpated jaw: Full range of motion, no popping or clicking	Exam Action 03/30/25 7:22 PM EDT
	Palpated lymph nodes of head and neck: Not palpable	Exam Action 03/30/25 7:23 PM EDT
	Palpated supraclavicular lymph nodes: Not palpable	Exam Action 03/30/25 7:23 PM EDT
	Palpated axillary lymph nodes: Not palpable	Exam Action 03/30/25 7:23 PM EDT
	Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported	Exam Action 03/30/25 7:23 PM EDT
	Auscultated breath sounds in anterior right upper lobe	Exam Action 03/30/25 7:23 PM EDT
	Auscultated breath sounds in anterior left upper lobe	Exam Action 03/30/25 7:23 PM EDT
	Auscultated breath sounds in anterior right middle lobe	Exam Action 03/30/25 7:23 PM EDT
	Auscultated breath sounds in anterior left mid-chest (upper lobe)	Exam Action 03/30/25 7:23 PM EDT
	Auscultated breath sounds in anterior right lower lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in anterior left lower lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior left upper lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior right upper lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior left mid-back (lower lobe)	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior right mid-back (lower lobe)	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior left lower lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior right lower lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior left lower lobe on side	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior left lower lobe near spine	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior right lower lobe near spine	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior right lower lobe on side	Exam Action 03/30/25 7:24 PM EDT
	Auscultated right temporal pulse	Exam Action 03/30/25 7:25 PM EDT
	Auscultated left temporal pulse	Exam Action 03/30/25 7:25 PM EDT
	Auscultated right carotid pulse	Exam Action 03/30/25 7:25 PM EDT
	Auscultated left carotid pulse	Exam Action 03/30/25 7:25 PM EDT
	Tested left pupillary reaction with penlight	Exam Action 03/30/25 7:25 PM EDT
	Tested right pupillary reaction with penlight	Exam Action 03/30/25 7:25 PM EDT
	Follow my fingers with just your eyes	Question 03/30/25 7:25 PM EDT
	Ok.
	Tested EOM to the upper left	Exam Action 03/30/25 7:26 PM EDT
	Tested EOM to the upper center	Exam Action 03/30/25 7:26 PM EDT
	Tested EOM to the upper right	Exam Action 03/30/25 7:26 PM EDT
	Tested convergence to the center	Exam Action 03/30/25 7:26 PM EDT
	Tested EOM to the lower right	Exam Action 03/30/25 7:26 PM EDT
	Tested EOM to the lower center	Exam Action 03/30/25 7:26 PM EDT
	Tested EOM to the lower left	Exam Action 03/30/25 7:26 PM EDT
	Tell me when you can no longer see my finger	Question 03/30/25 7:26 PM EDT
	Ok, I will.
	Tested peripheral vision	Exam Action 03/30/25 7:26 PM EDT
	Now.
	Examined fundus of right eye with ophthalmoscope	Exam Action 03/30/25 7:26 PM EDT
	Examined fundus of left eye with ophthalmoscope	Exam Action 03/30/25 7:27 PM EDT
	Um, that one’s kind of blurry.
	E D E O X F
	Um, that one’s kind of blurry.
	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 03/30/25 7:28 PM EDT
	I can’t read that line. It’s too little.
	I can’t read that line. It’s too little.
	That’s… I can’t really tell.
	Um, that one’s kind of blurry.
	E D E O X F
	P E C F D
	Tested visual acuity of right eye (left eye covered)	Exam Action 03/30/25 7:29 PM EDT
	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 with both eyes	Exam Action 03/30/25 7:30 PM EDT
	is the volume the same in both ears or louder in one ear?	Question 03/30/25 7:31 PM EDT
	Ok.
	Same in both ears.
	Performed Weber test with tuning fork	Exam Action 03/30/25 7:31 PM EDT
	Tell me when you no longer hear the ringing	Question 03/30/25 7:31 PM EDT
	Ok, I will.
	Now.
	Tell me when you no longer hear the ringing	Question 03/30/25 7:32 PM EDT
	Ok, I will.
	Now.
	Performed Rinne test on right ear with tuning fork	Exam Action 03/30/25 7:32 PM EDT
	Now.
	Four	Question 03/30/25 7:32 PM EDT
	Four.
	R.	Question 03/30/25 7:32 PM EDT
	R.
	Nine.	Question 03/30/25 7:33 PM EDT
	Nine.
	Performed whisper test in left ear	Exam Action 03/30/25 7:33 PM EDT
	F.	Question 03/30/25 7:33 PM EDT
	F.
	Eight	Question 03/30/25 7:33 PM EDT
	Eight.
	W.	Question 03/30/25 7:33 PM EDT
	W.
	Performed whisper test in right ear	Exam Action 03/30/25 7:33 PM EDT
	Tested gag reflex with tongue blade	Exam Action 03/30/25 7:33 PM EDT

Subjective Data Collection: 29 of 29 (100.0%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

Found:

Indicates an item that you found.

Available:

Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

Finding:

Established chief complaint

Finding:

Reports sore throat

(Found)

Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question:

Is your throat sore?

Finding:

Reports itchy throat

(Found)

Example Question:

Is your throat itchy?

Finding:

Reports itchy eyes

(Found)

Example Question:

Are your eyes itchy?

Finding:

Reports runny nose

(Found)

Example Question:

Do you have a runny nose?

History of Present Illness

Finding:

Asked about onset of symptoms

Finding:

Reports sore throat began 1 week ago

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How long has your throat been sore?

Finding:

Reports runny nose began 1 week ago

(Found)

Example Question:

When did your nose start running?

Finding:

Reports itchy eyes began 1 week ago

(Found)

Example Question:

When did your eyes start itching?

Finding:

Asked about aggravating factors for throat symptoms

Finding:

Reports throat pain is constant

(Found)

Example Question:

Is the throat pain constant?

Finding:

Reports throat pain is worse in the morning

(Available)

Example Question:

When does your sore throat feel the worst?

Finding:

Reports some soreness with swallowing

(Available)

Example Question:

Does it hurt when you swallow?

Finding:

Asked severity of throat discomfort

Finding:

Reports sore throat discomfort as mild to moderate

(Available)

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 runny nose is constant

(Found)

Example Question:

How often does your nose run?

Finding:

Followed up on nasal symptoms

Finding:

Denies itchy nose

(Available)

Example Question:

Does your nose itch?

Finding:

Denies sinus pain

(Available)

Example Question:

Do you feel any sinus pain?

Finding:

Denies sinus pressure

(Available)

Example Question:

Do you feel any sinus pressure?

Finding:

Denies sneezing

(Available)

Example Question:

Have you been sneezing?

Finding:

Followed up about character of nasal discharge

Finding:

Reports clear discharge

(Found)

Example Question:

What color is your mucus?

Finding:

Reports thin discharge

(Available)

Example Question:

Is the mucus thick?

Finding:

Denies pus

(Found)

Example Question:

Does your mucus have pus in it?

Finding:

Asked about eye symptoms

Finding:

Reports eye itching is constant

(Available)

Example Question:

Do your eyes constantly itch?

Finding:

Reports eye redness

(Available)

Example Question:

Are your eyes red?

Finding:

Asked related respiratory symptoms

Finding:

Reports breathing isn’t affected

(Found)

Example Question:

Have you had any changes in your breathing?

Finding:

Denies cough

(Available)

Example Question:

Do you have a cough?

Finding:

Denies chest tightness

(Available)

Example Question:

Does your chest feel tight?

Finding:

Asked about related asthma symptoms

Finding:

Denies recent wheezing

(Available)

Example Question:

Have you been wheezing?

Finding:

Denies increase in recent asthma symptoms

(Found)

Example Question:

Has your asthma been worse lately?

Finding:

Asked about perceived cause of symptoms

Finding:

Reports symptoms are similar to allergies

(Found)

Example Question:

Do you know what’s causing your symptoms?

Finding:

Reports symptoms don’t seem like a common cold

(Found)

Example Question:

Do you think you have a cold?

Finding:

Reports similarity to her sister’s hay fever symptoms

(Found)

Example Question:

Do you think you are having an allergic reaction?

Finding:

Asked about relieving factors for nose and eye symptoms

Finding:

Denies treatment for itchy eyes

(Found)

Example Question:

Have you treated your eyes with anything?

Finding:

Denies treatment for nasal symptoms

(Available)

Example Question:

Have you done anything for your runny nose?

Finding:

Denies taking antihistamine

(Available)

Example Question:

Have you taken any antihistamines?

Finding:

Denies taking decongestant

(Available)

Example Question:

Have you taken any decongestants?

Finding:

Asked about relieving factors for throat symptoms

Finding:

Reports lozenges as treatment

(Found)

Example Question:

Have you taken anything for your sore throat?

Finding:

Reports lozenges reduce symptoms

(Available)

Example Question:

Do the lozenges help?

Finding:

Reports ingesting lozenges every few hours

(Available)

Example Question:

How often do you have a lozenge?

Finding:

Reports drinking water reduces symptoms

(Found)

Example Question:

Does drinking water help?

Home Medications

Finding:

Confirmed home medications

Finding:

Reports no new medications

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Have you started taking any new medications?

Finding:

Followed up about inhaler use

Finding:

Reports using an inhaler to treat asthma symptoms

(Found)

Example Question:

Do you use an inhaler for your asthma?

Finding:

Reports inhaler is albuterol (Proventil)

(Available)

Example Question:

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

Finding:

Reports last use of inhaler was 1 week ago

(Available)

Example Question:

When did you last use your inhaler?

Finding:

Reports typical inhaler use is 2 – 3 times a week

(Available)

Example Question:

How often do you use your inhaler?

Finding:

Reports using 2 – 3 puffs of inhaler when used

(Available)

Example Question:

How many puffs of your inhaler do you use?

Finding:

Reports prescribed dosage is 2 puffs

(Available)

Example Question:

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

Social Determinants of Health

Finding:

Asked about environmental exposure to allergens

Finding:

Denies exposure to cats

(Found)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

Have you been recently exposed to any allergens?

Finding:

Denies exposure to mold or mildew

(Available)

Example Question:

Do you have mold in your house?

Finding:

Denies exposure to dust

(Found)

Example Question:

Do you have dust in your house?

Finding:

Denies exposure to irritants in work environment

(Available)

Example Question:

Are you allergic to anything at work?

Finding:

Reports changing bedding once a week

(Available)

Example Question:

How often do you change your bedding?

Finding:

Denies history of cigarette smoking

(Available)

Example Question:

Have you smoked cigarettes recently?

Finding:

Denies recent exposure to secondhand smoke

(Available)

Example Question:

Have you been exposed to secondhand smoke recently?

Finding:

Asked about healthcare access

Finding:

Reports last vision exam was in childhood

(Available)

Example Question:

When was your last vision test?

Finding:

Reports last hearing test was in childhood

(Available)

Example Question:

When was your last hearing test?

Finding:

Reports dental visit within the last 2 years

(Available)

Example Question:

When did you last see the dentist?

Finding:

Reports regular dental visits in childhood

(Available)

Example Question:

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

Finding:

Denies vision insurance

(Available)

Example Question:

Do you have vision insurance?

Finding:

Denies dental insurance

(Available)

Example Question:

Do you have dental insurance?

Relevant Medical History

Finding:

Confirmed allergies

Finding:

Reports known allergy to cats

(Available)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Can you confirm that you’re allergic to cats?

Finding:

Reports known allergy to dust

(Available)

Example Question:

Are you allergic to dust?

Finding:

Denies seasonal allergies

(Available)

Example Question:

Do you have seasonal allergies?

Review of Systems

Finding:

Asked about constitutional health

Finding:

Denies recent or frequent illnesses

(Available)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Have you been sick recently?

Finding:

Denies chills

(Available)

Example Question:

Have you had any chills?

Finding:

Denies fever

(Available)

Example Question:

Have you had a fever?

Finding:

Reports low energy level

(Available)

Example Question:

Have you felt fatigued?

Finding:

Denies nausea or vomiting

(Available)

Example Question:

Have you felt nauseous?

Finding:

Asked about review of systems for head

Finding:

Reports occasional headaches

(Found)

Example Question:

Do you ever get headaches?

Finding:

Denies current headache

(Available)

Example Question:

Do you have a headache currently?

Finding:

Denies history of head injury

(Available)

Example Question:

Have you ever had a head injury?

Finding:

Denies lightheadedness

(Available)

Example Question:

Do you ever get lightheaded?

Finding:

Followed up on headaches

Finding:

Reports headaches occur once a week

(Found)

Example Question:

How often do you get headaches?

Finding:

Reports headaches last a few hours

(Available)

Example Question:

How long do your headaches last?

Finding:

Reports headaches feel tight and throbbing

(Available)

Example Question:

How would you describe your headaches?

Finding:

Reports headache location is behind her forehead

(Found)

Example Question:

Where do you feel your headaches?

Finding:

Reports headache pain as a 3 or 4

(Available)

Example Question:

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

Finding:

Reports treating headaches with acetaminophen (Tylenol)

(Available)

Example Question:

How do you treat your headaches?

Finding:

Reports reading and studying seem to cause headaches

(Found)

Example Question:

What seems to cause your headaches?

Finding:

Asked about review of systems for eyes

Finding:

Reports occasional blurry vision

(Found)

Example Question:

Do you have blurry vision?

Finding:

Reports worsening vision

(Found)

Example Question:

Has your vision gotten worse?

Finding:

Denies eye pain

(Available)

Example Question:

Have you had eye pain?

Finding:

Denies dry eyes

(Available)

Example Question:

Have you had dry eyes?

Finding:

Denies corrective lenses

(Available)

Example Question:

Do you have glasses or contacts?

Finding:

Followed up on vision problems

Finding:

Reports blurry vision as fuzzy letters

(Available)

Example Question:

Can you describe your blurry vision?

Finding:

Reports blurry vision occurs when reading for long periods

(Found)

Example Question:

When do you get blurry vision?

Finding:

Reports blurry vision occurs after 2+ hours of reading

(Available)

Example Question:

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

Finding:

Reports that blurry vision and headaches often coincide

(Available)

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)

Example Question:

Have you had ear problems?

Finding:

Denies change in hearing

(Available)

Example Question:

Have you had any changes in your hearing?

Finding:

Denies ear pain

(Available)

Example Question:

Have you had ear pain?

Finding:

Denies ear discharge

(Available)

Example Question:

Have you noticed ear discharge?

Finding:

Asked about review of systems for nose

Finding:

Denies change in sense of smell

(Available)

Example Question:

Have you had any changes in your sense of smell?

Finding:

Denies nasal or sinus surgeries

(Available)

Example Question:

Have you ever had a nasal surgery?

Finding:

Denies nosebleeds

(Available)

Example Question:

Do you ever get nosebleeds?

Finding:

Asked about review of systems for mouth and jaw

Finding:

Denies general mouth problems

(Found)

Example Question:

Have you ever had problems with your mouth?

Finding:

Denies change in sense of taste

(Available)

Example Question:

Has your sense of taste changed?

Finding:

Denies dry mouth

(Available)

Example Question:

Have you had dry mouth recently?

Finding:

Denies history of oral surgery

(Available)

Example Question:

Have you ever had oral surgery?

Finding:

Denies mouth pain

(Available)

Example Question:

Do you have mouth pain?

Finding:

Denies mouth sores

(Available)

Example Question:

Do you have any mouth sores?

Finding:

Denies gum problems

(Available)

Example Question:

Do you have any problems with your gums?

Finding:

Denies tongue problems

(Available)

Example Question:

Do you have any problems with your tongue?

Finding:

Denies jaw problems

(Found)

Example Question:

Do you have any problems with your jaw?

Finding:

Asked about review of systems for dentation

Finding:

Denies current dental problems

(Found)

Example Question:

Do you have any current dental problems?

Finding:

Reports a few cavities in childhood

(Available)

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

(Available)

Example Question:

Do you get strep throat often?

Finding:

Denies lymph node problems

(Available)

Example Question:

Do you have any problems with your lymph nodes?

Finding:

Denies history of general throat problems

(Available)

Example Question:

Do you have a history of throat problems?

Finding:

Denies voice changes

(Available)

Example Question:

Have you noticed any changes to your voice?

Finding:

Denies history of tonsil problems

(Available)

Example Question:

Do you have any history of tonsil problems?

Finding:

Denies general neck pain

(Available)

Example Question:

Do you have neck pain?

Relevant Family History

Finding:

Asked about relevant family history

Finding:

Reports sister with hay fever

(Available)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

Do you have any family members with allergies?

Finding:

Denies family history of vision problems

(Available)

Example Question:

Do vision problems run in your family?

Finding:

Denies family history of sinus problems

(Available)

Example Question:

Do sinus problems run in your family?

Finding:

Denies family history of ear or hearing problems

(Available)

Example Question:

Do hearing problems run in your family?

Finding:

Denies family history of mouth, throat, or gland problems

(Found)

Example Question:

Do you have any family history of throat problems?

Finding:

Denies family history of headache or migraine

Objective Data Collection: 25 of 25 (100%)

Correct
Partially correct

Incorrect
Missed

Inspected head and face

1 of 1 point

Skull Symmetry (1/3 point)

Symmetric

Facial Feature Symmetry (1/3 point)

Symmetric

Appearance (1/3 point)

Papules, pustules, or comedones
Excessive hair growth
Red, chapped nose

Inspected eyes and orbital area

1 of 1 point

Orbital Area (1/4 point)

No visible abnormal findings

Sclera (1/4 point)

Injection

Conjunctiva (1/4 point)

Moist and pink

Conjunctival Discharge (1/4 point)

No discharge

Inspected nasal cavities

1 of 1 point

Color (1/4 point)

Pale
Bluish

Discharge (1/4 point)

Clear discharge

Turbinate Patency (1/4 point)

Patent

Observations (1/4 point)

No additional visible abnormal findings

Inspected ears

1 of 1 point

Right: Auditory Canal Color (1/10 point)

Pink

Right: Tympanic Membrane Color (1/10 point)

Pearly gray

Right: Tympanic Membrane Appearance (1/10 point)

No visible abnormal findings

Right: Cone Of Light (1/10 point)

5:00

Right: Discharge (1/10 point)

No discharge

Left: Auditory Canal Color (1/10 point)

Pink

Left: Tympanic Membrane Color (1/10 point)

Pearly gray

Left: Tympanic Membrane Appearance (1/10 point)

No visible abnormal findings

Left: Cone Of Light (1/10 point)

7:00

Left: Discharge (1/10 point)

No discharge

Inspected mouth and throat

1 of 1 point

Oral Mucosa (1/6 point)

Moist and pink

Tonsils (1/6 point)

Edema

Tonsil Grade (1/6 point)

1+: Tonsils <25% of space between pillars

Posterior Oropharynx Color (1/6 point)

Erythemic

Posterior Oropharynx Texture (1/6 point)

Cobblestoning

Post Nasal Drip (1/6 point)

Clear discharge

Inspected neck

1 of 1 point

Symmetry (1/2 point)

Symmetric

Appearance (1/2 point)

Discoloration

Palpated scalp

1 of 1 point

Tenderness (1/2 point)

None reported

Observations (1/2 point)

No additional abnormal findings

Palpated sinuses

1 of 1 point

Frontal (1/2 point)

None reported

Maxillary (1/2 point)

None reported

Palpated temporal arteries

1 of 1 point

Right: Vibration (1/4 point)

No thrill

Right: Intensity (1/4 point)

2+ Expected

Left: Vibration (1/4 point)

No thrill

Left: Intensity (1/4 point)

2+ Expected

Palpated carotid arteries

1 of 1 point

Right: Vibration (1/4 point)

No thrill

Right: Intensity (1/4 point)

2+ Expected

Left: Vibration (1/4 point)

No thrill

Left: Intensity (1/4 point)

2+ Expected

Palpated jaw

1 of 1 point

Observations (1/1 point)

No palpable abnormal findings

Palpated lymph nodes

1 of 1 point

Head And Neck (1/3 point)

No palpable nodes

Supraclavicular (1/3 point)

No palpable nodes

Axillary (1/3 point)

No palpable nodes

Palpated thyroid gland

1 of 1 point

Observations (1/2 point)

No palpable abnormal findings

Tenderness (1/2 point)

None reported

Auscultated breath sounds

1 of 1 point

Breath Sounds (1/3 point)

Present in all areas

Adventitious Sounds (1/3 point)

No adventitious sounds

Location (1/3 point)

All areas clear

Auscultated temporal arteries

1 of 1 point

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Auscultated carotid arteries

1 of 1 point

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Tested pupillary reaction

1 of 1 point

Observations With Penlight (1/1 point)

No visible abnormal findings (PERRL)

Tested extraocular eye movements

1 of 1 point

Cardinal Fields (1/2 point)

No visible abnormal findings

Convergence (1/2 point)

No visible abnormal findings

Tested peripheral vision

1 of 1 point

Observations (1/1 point)

No abnormal findings

Examined fundus with ophthalmoscope

1 of 1 point

Right: Retina (1/4 point)

Cotton wool bodies

Right: Disc Margin (1/4 point)

Sharp

Left: Retina (1/4 point)

No visible abnormal findings

Left: Disc Margin (1/4 point)

Sharp

Tested visual acuity

1 of 1 point

Right (1/2 point)

20/40

Left (1/2 point)

20/20

Performed Weber test

1 of 1 point

Results (1/1 point)

Normal

Performed Rinne test

1 of 1 point

Right (1/2 point)

Normal

Left (1/2 point)

Normal

Performed whisper test

1 of 1 point

Right (1/2 point)

Normal

Left (1/2 point)

Normal

Tested gag reflex

1 of 1 point

Observations (1/1 point)

Intact

Education & Empathy : 1 of 5 (20.0%)

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.

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 here today	Question 04:31 AM EDT
	My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
	I am sorry for that	Empathize 04:31 AM EDT
	I appreciate you saying that.
	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

Not Followed Up

	Description: Tina describes her symptoms as being similar to allergies.
	what do you think has caused the symptoms?	Question 04:45 AM EDT
	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.
	What relieves the symptoms?	Question 04:45 AM EDT
	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.”

3 Medications

Not Followed Up

	Description: Tina describes her medication regimen.
	What relieves nose and eye symptoms?	Question 04:47 AM EDT
	All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
	Do you use medications?	Question 04:48 AM EDT
	No, I haven’t done anything to try to make my eyes less itchy.
	Do you use an inhaler	Question 04:48 AM EDT
	Yeah, I use it when my asthma acts up.
	Are you exposed to allergens?	Question 04:48 AM EDT
	Not lately.
	How is your healthcare access	Question 04:49 AM 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.
	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 head problem?	Question 04:49 AM EDT
	Just like in general? I get headaches sometimes.
	What causes the headaches?	Question 04:50 AM EDT
	When I get headaches, it’s usually just from reading. I only get them about once a week and it doesn’t really hurt on one side or the other. The pain is mostly behind both eyes.
	Do you have vision problems?	Question 04:50 AM EDT
	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.
	Do you have vision problems?	Question 04:50 AM 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.
	Do you have any ears problem	Question 04:50 AM EDT
	No, my ears are fine right now.
	Do you have any mouth or jaw problem?	Question 04:50 AM EDT
	No, that’s not where I’m having problems. [AUDIO COMING SOON]
	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.”

Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Ms. Jones is a 28 y/o African American woman who visits the clinic due to sore and itchy throat, itchy eyes and runny nose which has lasted for one week. No aggravating symptoms but sore throat is worse in the morning. She rates the pain as 4/10. She relieves pain with throat lozenges. Has soreness while swallowing. She has a clear nose discharge. Not had any treatment. No cough or other illness. No fever, chills or sweats. Social History: Not exposed to irritants. does not use tobacco, alcohol or drugs. ROS Head: Occasional headaches Eyes: Vision worsening Ears: no discharge or pain Mouth/throat: Sore, itchy Nose/sinuses: Pain outside of nose Respiratory: No shortness of breath	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. Reports headaches while studying. • 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 She is alert and well oriented Head: Symmetric, no scalps Eyes: Bilateral eyes Ears: No inflammation, whisper normal Nose: Nosal mucosa is boggy and pale Mouse/Throat: Moist buccal mucosa Neck: Thyroid is smooth Respiratory: Symmetrical chest	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.
Assessment Allergic Rhinitis	Allergic Rhinitis
Plan Continue monitoring symptoms Initiate loratadine 10mg by mouth daily Increase intake of water Avoid triggers Seek care in case of uncontrollable episodes Come for check up in 2 weeks	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.

Are you struggling to create a sound and comprehensive nursing paper? Do you feel overwhelmed with the amount of time and effort it takes to write a good piece? Are you looking for the best nursing paper writing service that can assist you in your nursing paper needs? Look no further than our skilled team of professional writers who specialize in providing high-quality papers with the best nursing paper writing services reviews. Make your order at nursingpaperhelp.com

Needs help with similar assignment?

We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper

Get Answer Over WhatsApp

Order Paper Now

Needs help with similar assignment?

About Nursingpaperhelp

Quick Links

We Accept

Contact Us