Tina Jones HEENT Health Assessment – January 2023

Transcript

Started: Feb 07, 2023 | Total Time: 40 min

All Lines (107)Interview Questions (47)Statements (0)Exam Actions (60)

	Hello!
	Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
	What is the situation?
	It’s 8 a.m. on Tina Jones’ first morning as a patient here at Shadow General Hospital. When Ms. Jones was admitted at midnight last night for a foot wound, she mentioned a history of headaches and allergies. Your role in this simulation is that of a healthcare provider who will perform an examination of Ms. Jones’ HEENT systems: Head, Eyes, Ears, Nose, and Throat. Examination of all of these systems is often necessary to examine any one of them, given their close proximity and physiological relationships.
	What are my objectives in this assessment?
	In your interview with Ms. Jones, you will ask about the health of her HEENT systems so that you can identify any issues and document findings accurately. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to HEENT systems so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her HEENT systems. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones’ HEENT systems to gather objective data about the systems’ health and physiology. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
	What else will this exam involve?
	You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
	How will I be evaluated?
	In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment on average takes between 60 and 75 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
	How does this assignment prepare me for the real world?
	In this assessment, you will become familiarized with the structure and content of HEENT exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data.
	In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What physical exam findings would you look for in a patient with allergies?
	Physical exams for a patient with allergies include breathing, sniffing, nasal congestion, dizziness, skin reactions among others.
	Time to begin.
	Hello, my name is Nukol. I will be your nurse today.
	Hey.
	What brings you here today?
	Well, I came in last night for my foot. It just wasn’t healing right, and it really hurt.
	Okay, do you have headaches? (Clarified to Have you had headaches recently?.)
	My head’s fine right now, I do get headaches sometimes. (Clarified to if I have had headaches recently.)
	How frequent are the headaches?
	Maybe every 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.
	What are the durations of the headaches?
	Yeah, I get them when I’m studying.
	Duration of the headaches? (Clarified to How long do the headaches last?.)
	A few hours, I guess. (Clarified to how long my headaches last.)
	Where is the location of the headaches?
	It’s kind of behind my forehead.
	What is the headache pain on a scale?
	Not too bad. . . I’d say about 2. Or a 3 if I really push it.
	How do you treat the headache?
	I just take some Tylenol. The gel kind. Usually that and going to bed helps with the headaches. [AUDIO COMING SOON]
	How is the vision?
	It’s okay, I guess? Sometimes my vision gets a little blurry.
	When did the blurry vision start?
	I’m not sure — Maybe over the last year or so.
	What reliefs the blurry vision? (Clarified to Do you do anything to relieve the blurry vision?.)
	Usually if I stop studying and rest it gets a better. (Clarified to if I do anything to relieve my blurry vision.)
	How do take care of your vision?
	I don’t really do much, I don’t think. [AUDIO COMING SOON]
	What triggers the eye symptoms?
	Just when I’m around a cat, which isn’t very often. Sometimes dust will do it, too. [AUDIO COMING SOON]
	How do you treat the eye symptoms?
	If I’m having an allergic reaction, I just rinse my eyes out in the shower. [AUDIO COMING SOON]
	Do you have nasal problems?
	Sometimes my nose gets runny. It’s fine right now, though. [AUDIO COMING SOON]
	Do you have sinus problems?
	My sinuses are fine right now.
	What triggers the nasal problems?
	Cats or dust are usually what does it.
	Do you take alcohol?
	I do sometimes, yeah, when I go out with my friends.
	Do you take tobacco?
	No. I think it’s gross.
	Do you have ear problems?
	No, my ears are fine right now.
	Do you have hearing problems?
	No.
	Do you have any mouth issue?
	No.
	Do you have dentition issues?
	Does dentition mean dental? Yeah, my teeth are fine. [AUDIO COMING SOON]
	Do you have throat issues?
	No, my throat has been fine.
	Do you have lymph node problems?
	Not that I’ve noticed.
	Do you have thyroid problems?
	No, I never have.
	Do you have a family history of headaches?
	No, not really.
	Do you have a family history of eye problems?
	No.
	Do you have a family history of ear problems?
	No.
	Do you have a family history of nasal problems?
	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.
	Do you have a family history of mouth problems?
	No, not really.
	Do you have a family history of throat problems?
	No.
	Checked vitals
	What is the pain rate on a scale?
	I’d say it’s down to around a 6 out of 10 now.
	Inspected general face
	Inspected forehead and scalp
	Inspected nose and mouth
	Inspected left side of face
	Inspected back of head
	Inspected right side of face
	Inspected general face
	Inspected right side of face
	Inspected back of head
	Inspected left side of face
	Inspected general face
	Inspected right orbital area and sclera
	Inspected left orbital area and sclera
	Inspected upper conjunctiva
	Inspected lower conjunctiva
	Performed otoscopic examination of right naris
	Performed otoscopic examination of left naris
	Performed otoscopic examination of right ear
	Performed otoscopic examination of left ear
	Inspected mouth
	Inspected front of neck
	Inspected right side of neck
	Inspected back of neck
	Inspected left side of neck
	Inspected front of neck
	Inspected left side of neck
	Inspected back of neck
	Inspected right side of neck
	Inspected front of neck
	Inspected left side of neck
	Inspected front of neck
	Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported
	Palpated frontal sinuses: No tenderness reported
	Palpated maxillary sinuses: No tenderness reported
	Palpated left carotid artery: No thrill, 2+
	Palpated right carotid artery: No thrill, 2+
	Palpated jaw: Full range of motion, no popping or clicking
	Palpated lymph nodes of head and neck: Not palpable
	Palpated supraclavicular lymph nodes: Not palpable
	Palpated axillary lymph nodes: Not palpable
	Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported
	Auscultated right carotid artery
	Auscultated left carotid artery
	Tested left pupillary reaction with penlight
	Tested right pupillary reaction with penlight
	Follow my finger with just your eyes
	Ok.
	Tested EOM to the upper left
	Tested EOM to the upper center
	Tested convergence to the center
	Tested EOM to the upper right
	Tested EOM to the lower center
	Tested EOM to the lower right
	Tested convergence to the center
	Tested EOM to the lower left
	Tell me when you can no longer see my fingers
	Ok, I will.
	Tested peripheral vision
	Now.
	F P
	E D F C Z P
	I can’t read that line. It’s too little.
	I can’t read that line. It’s too little.
	D E F P O T E C
	Tested visual acuity with both eyes
	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)
	P E C F D
	E D F C Z P
	F E L O P Z D
	D E F P O T E C
	Tested visual acuity of left eye (right eye covered)
	I can’t read that line. It’s too little.
	F.
	F.
	Eight.
	Eight.
	W.
	W.
	Performed whisper test in right ear
	Four
	Four.
	R.
	R.
	Nine
	Nine.
	Performed whisper test in left ear

 

 

Subjective Data Collection: 34 of 34 (100.0%)

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.

Relevant Medical History

Finding:

Asked about head problems

Finding:

Reports occasional headaches

(Found)

Pro Tip: Headaches can be caused a variety of ways, such as when sinus problems result in increased pressure buildup. Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences.

Example Question:

Do you get headaches?

Finding:

Denies current headache

(Found)

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

Example Question:

Do you currently have a headache?

Finding:

Denies head problems other than headaches

(Available)

Pro Tip: Broad, open questions will allow Tina to describe, in her own words, any specific head conditions and symptoms that she is experiencing.

Example Question:

Other than headaches, are you experiencing head problems?

Finding:

Asked about frequency of headaches

Finding:

Reports headaches occur once a week

(Found)

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

Example Question:

How frequently do your headaches occur?

Finding:

Asked about duration of headaches

Finding:

Reports headaches last a few hours

(Found)

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

Example Question:

How long do your headaches last?

Finding:

Asked about character and location of headaches

Finding:

Reports headaches as tight and throbbing

(Available)

Pro Tip: Specifying what the pain feels like can narrow and define the type of headache Tina is experiencing. Soliciting this information allows you to more accurately treat her symptoms.

Example Question:

What do your headaches feel like?

Finding:

Reports headache located behind her eyes

(Found)

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

Example Question:

Where do you feel your headaches?

Finding:

Asked to rate headache pain on a scale

Finding:

Reports headaches as a 2/10 or 3/10

(Found)

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

Example Question:

On a scale of 1 to 10, how bad are your headaches?

Finding:

Asked about headache treatment

Finding:

Reports treating headaches with acetaminophen (Tylenol)

(Found)

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

Example Question:

Do you take anything to treat your headaches?

Finding:

Reports resting to treat headache

(Found)

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

Example Question:

Do you do anything to treat your headaches?

Finding:

Reports acetaminophen (Tylenol) and rest usually resolve symptoms

(Found)

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

Example Question:

What helps with your headaches?

Finding:

Asked about headache triggers

Finding:

Reports headaches only happen when reading or studying

(Found)

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

Example Question:

When do you get headaches?

Finding:

Reports that blurry vision and headaches often coincide

(Available)

Pro Tip: Soliciting information about whether Tina’s headaches coincide with her blurry vision will allow you to consider whether the two are related and how then to customize treatment.

Example Question:

Do your headaches coincide with your blurry vision?

Finding:

Asked about vision

Finding:

Reports occasional blurry vision

(Found)

Pro Tip: Broad, open questions will allow Tina to describe, in her own words, any specific vision conditions and symptoms that she is experiencing.

Example Question:

Have you been having problems with your vision?

Finding:

Asked about onset and frequency of blurry vision

Finding:

Reports worsening vision began within the past year

(Found)

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

Example Question:

When did your vision begin worsening?

Finding:

Reports blurry vision only occurs when reading for long periods

(Available)

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

Example Question:

When does your blurry vision occur?

Finding:

Reports noticing blurry vision increasing in the past few months

(Available)

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

Example Question:

Have you been getting blurry vision more often?

Finding:

Asked about relieving factors for blurry vision

Finding:

Reports that resting eyes helps

(Found)

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

Example Question:

What makes your blurry vision go away?

Finding:

Asked about vision care

Finding:

Reports last vision exam was in childhood

(Available)

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

Example Question:

When was your last vision exam?

Finding:

Denies use of corrective lenses

(Available)

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

Example Question:

Do you use corrective lenses?

Finding:

Asked about additional eye problems

Finding:

Reports occasional itchy eyes

(Found)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina’s eyes itch can reveal one such trigger.

Example Question:

Does your cat allergy make your eyes itch?

Finding:

Reports occasional eye redness

(Available)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina’s eyes become red can reveal one such trigger.

Example Question:

Do you have eye redness?

Finding:

Denies eye pain

(Available)

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

Example Question:

Do you have eye pain?

Finding:

Denies eye dryness

(Available)

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

Example Question:

Do you have eye dryness?

Finding:

Asked about triggers for eye symptoms

Finding:

Reports cat allergy is a trigger for itchy eyes

(Found)

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

Example Question:

Does being around cats make your eyes itch?

Finding:

Reports dust is a trigger for itchy eyes

(Found)

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

Example Question:

Does dust make your eyes itch?

Finding:

Asked about treatment of eye symptoms

Finding:

Denies taking medication for itchy eyes

(Available)

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

Example Question:

Are you taking medication for your itchy eyes?

Finding:

Asked about nasal problems

Finding:

Reports occasional runny nose

(Found)

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

Example Question:

Do you have general nose problems?

Finding:

Denies nosebleeds

(Available)

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

Example Question:

Have you had nosebleeds?

Finding:

Asked about sinus problems

Finding:

Denies frequent sinus problems

(Found)

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

Example Question:

Do you have frequent sinus congestion?

Finding:

Followed up on trigger of nasal problem

Finding:

Reports cat allergy is trigger for runny nose

(Found)

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

Example Question:

Do your allergies trigger your runny nose?

Finding:

Followed up on treatment of nasal problem

Finding:

Denies taking medication for runny nose

(Available)

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

Example Question:

Are you taking any medication for your runny nose?

Finding:

Reports treatment is avoiding trigger

(Available)

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

Example Question:

How have you been treating your runny nose?

Finding:

Reports treatment is showering

(Found)

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

Example Question:

How have you been treating your runny nose?

Finding:

Asked about current nasal problems

Finding:

Denies current runny nose

(Found)

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

Example Question:

Do you have a runny nose right now?

Risk Factors

Finding:

Asked about alcohol intake

Finding:

Reports last alcoholic drink was 3 weeks ago

(Available)

Pro Tip: Confirming when a patient had her last alcohol intake is important, because she will receive medications while admitted, and alcohol is often contraindicated.

Example Question:

When was your last alcoholic drink?

Finding:

Reports no more than 2 or 3 alcoholic drinks in one sitting

(Available)

Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient, including to the HEENT systems.

Example Question:

How many alcoholic drinks do you typically have in one sitting?

Finding:

Reports no more than 1 or 2 nights a week drinking alcohol

(Available)

Pro Tip: Finding out how many nights a week your patient has alcohol gives insight into potential habits or abuse, and how they may be affecting the HEENT systems.

Example Question:

How many alcoholic drinks do you typically have in a week?

Finding:

Asked about tobacco use

Finding:

Denies tobacco use

(Found)

Pro Tip: Smoking tobacco can affect a patient’s head, ears, eyes, nose, and throat in numerous ways. Asking Tina about her use of any tobacco will help you understand the health of her HEENT systems.

Example Question:

Do you smoke tobacco?

Finding:

Denies vaping

(Available)

Pro Tip: Smoking tobacco can affect a patient’s head, ears, eyes, nose, and throat in numerous ways. Asking Tina about her use of any tobacco will help you understand the health of her HEENT systems.

Example Question:

Do you vape?

Review of Systems

Finding:

Asked about ear problems

Finding:

Denies ear pain

(Available)

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

Example Question:

Do you have ear pain?

Finding:

Denies ear discharge

(Available)

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

Example Question:

Do you have ear discharge?

Finding:

Denies vertigo

(Available)

Pro Tip: Vertigo can be caused by multiple issues in the inner ear. Asking Tina whether she has vertigo can help you assess whether a deeper ear issue is at play.

Example Question:

Do you have vertigo?

Finding:

Reports using cotton swabs in ears weekly

(Available)

Pro Tip: A patient who uses cotton swabs to clean their ears risks damaging their ear drums and causing irritation or hearing difficulty. Asking Tina if she uses cotton swabs in her ears determines her health literacy and what education she could benefit from.

Example Question:

Do you use cotton swabs in your ears?

Finding:

Asked about hearing

Finding:

Denies hearing changes

(Found)

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

Example Question:

Have you had changes in your hearing?

Finding:

Denies difficulty hearing

(Found)

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

Example Question:

Do you have difficulty hearing?

Finding:

Asked about mouth problems

Finding:

Denies bleeding gums

(Found)

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

Example Question:

Have you had bleeding gums?

Finding:

Denies mouth sores

(Found)

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

Example Question:

Have you had mouth sores?

Finding:

Denies tongue problems

(Found)

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

Example Question:

Have you had tongue problems?

Finding:

Denies dry mouth

(Found)

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

Example Question:

Have you had a dry mouth?

Finding:

Asked about dentition

Finding:

Denies current dental problems

(Available)

Pro Tip: Asking Tina if she’s had any dental problems might indicate a problem area that has caused infection, decay, pain, or other conditions that need treatment.

Example Question:

Do you have current dental problems?

Finding:

Reports visit within the last 2 years

(Available)

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

Example Question:

When was your last dental visit?

Finding:

Reports regular visits in childhood

(Available)

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

Example Question:

Did you visit the dentist regularly as a child?

Finding:

Reports only having a few cavities in childhood

(Available)

Pro Tip: Asking Tina about whether she had cavities as a child will help you contextualize her current dental health and whether she has maintained oral hygiene.

Example Question:

Did you have cavities as a child?

Finding:

Reports flossing

(Available)

Pro Tip: Flossing is a crucial part of a patient’s dental health and hygiene. Asking Tina if she flosses indicates her health literacy, compliance to recommended health guidelines, and need for education.

Example Question:

Do you floss?

Finding:

Asked about throat problems

Finding:

Denies sore throat

(Found)

Pro Tip: Throat problems can cause discomfort and indicate a more serious condition. Asking Tina about any sore throat she has had allows you to determine if follow-up questions are needed.

Example Question:

Have you had a sore throat?

Finding:

Denies voice changes

(Available)

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

Example Question:

Has your voice changed?

Finding:

Denies difficulty swallowing

(Available)

Pro Tip: Difficulty swallowing can indicate a multitude of underlying neurological or gastrointestinal disorders. Asking Tina whether she has dysphagia can help you determine whether to look for causes.

Example Question:

Do you have difficulty swallowing?

Finding:

Asked about lymph node problems

Finding:

Denies painful lymph nodes

(Found)

Pro Tip: Painful lymph nodes may appear in the neck when an infection is present. Asking Tina whether her lymph nodes have been painful will solicit a history of her condition.

Example Question:

Have your lymph nodes been painful?

Finding:

Denies swollen lymph nodes

(Available)

Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether her lymph nodes have been swollen will solicit a history of her condition.

Example Question:

Have your lymph nodes been swollen?

Finding:

Asked about thyroid problems

Finding:

Denies thyroid problems

(Found)

Pro Tip: The thyroid can be affected by a multitude of serious conditions and can cause throat pain and impaired functioning. Asking Tina about any thyroid problems she may have allows you to assure she receives necessary care.

Example Question:

Have you been diagnosed with thyroid problems?

Relevant Family History

Finding:

Asked family history of head problems

Finding:

Denies family history of head problems

(Found)

Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of head problems can reveal generational patterns.

Example Question:

Do head problems run in your family?

Finding:

Asked family history of eye problems

Finding:

Denies family history of eye problems

(Found)

Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of eye problems can reveal generational patterns.

Example Question:

Do you have a family history of eye problems?

Finding:

Asked family history of ear problems

Finding:

Denies family history of ear problems

(Found)

Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of ear problems can reveal generational patterns.

Example Question:

Do ear problems run in your family?

Finding:

Denies family history of hearing loss

(Found)

Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of hearing loss can reveal generational patterns.

Example Question:

Do you have a family history of hearing loss?

Finding:

Asked family history of nasal problems

Finding:

Reports sister has regular hay fever

(Found)

Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of hay fever can reveal generational patterns.

Example Question:

Has anyone in your family had hay fever?

Finding:

Asked family history of mouth problems

Finding:

Denies family history of general mouth problems

(Found)

Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of mouth problems can reveal generational patterns.

Example Question:

Do mouth problems run in your family?

Finding:

Denies family history of mouth cancer

(Available)

Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of dental problems can reveal generational patterns.

Example Question:

Do you have a family history of dental problems?

Finding:

Denies family history of dental problems

(Available)

Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of mouth cancer can reveal generational patterns.

Example Question:

Do you have a family history of mouth cancer?

Finding:

Asked family history of throat and surrounding gland problems

Finding:

Denies family history of thyroid problems

(Available)

Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of thyroid problems can reveal generational patterns.

Example Question:

Do thyroid problems run in your family?

Finding:

Denies family history of lymph node cancers

(Available)

Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of lymph node cancers can reveal generational patterns.

Example Question:

Do you have a family history of lymph node cancers?

Finding:

Denies family history of throat cancer

 

Objective Data Collection: 17.85 of 19 (93.95%)

•  Correct
•  Partially correct

•  Incorrect
•  Missed

 Inspected head and face

1 of 1 point

 

Skull Symmetry (1/3 point)

•  Symmetric
•  Asymmetric

Facial Feature Symmetry (1/3 point)

•  Symmetric
•  Asymmetric

Appearance (1/3 point)

•  No visible abnormal findings
•  Rash
•  Papules, pustules, or comedones
•  Freckles, moles, or birth mark
•  Excessive hair growth
•  Evidence of skin trauma (scar, laceration, or bruising)

 Inspected eyes and orbital area

0.75 of 1 point

 

Orbital Area (1/4 point)

•  No visible abnormal findings
•  Ptosis
•  Swelling
•  Lesion

Sclera (No point)

•  White
•  Yellow tint
•  Redness

Conjunctiva (1/4 point)

•  Moist and pink
•  Dry appearance
•  Redness
•  Swelling

Conjunctival Discharge (1/4 point)

•  No discharge
•  Clear, watery discharge
•  Purulent discharge

 Inspected nasal cavities

0.5 of 1 point

 

Color (No point)

•  Pink
•  Red
•  Bluish

Discharge (No point)

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

Turbinate Patency (1/4 point)

•  Patent
•  Decreased patency
•  Not patent

Observations (1/4 point)

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

 Inspected ears

1 of 1 point

 

Right: Auditory Canal Color (1/10 point)

•  Pink
•  Red
•  Pallor

Right: Tympanic Membrane Color (1/10 point)

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

Right: Tympanic Membrane Appearance (1/10 point)

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

Right: Cone Of Light (1/10 point)

•  5:00
•  Cone of light distorted

Right: Discharge (1/10 point)

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

Left: Auditory Canal Color (1/10 point)

•  Pink
•  Red
•  Pallor

Left: Tympanic Membrane Color (1/10 point)

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

Left: Tympanic Membrane Appearance (1/10 point)

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

Left: Cone Of Light (1/10 point)

•  7:00
•  Cone of light distorted

Left: Discharge (1/10 point)

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

 Inspected mouth and throat

0.6 of 1 point

 

Oral Mucosa (1/5 point)

•  Moist and pink
•  Dry appearance
•  Redness

Throat Color (1/5 point)

•  Pink
•  Red

Throat Texture (1/5 point)

•  No abnormal findings
•  Cobblestoning
•  Exudate

Tonsils (No point)

•  No visible abnormal findings
•  Swelling
•  Redness

Post Nasal Drip (No point)

•  No discharge
•  Clear discharge
•  Purulent discharge

 Inspected neck

1 of 1 point

 

Symmetry (1/2 point)

•  Symmetric
•  Asymmetric

Appearance (1/2 point)

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

 Palpated scalp

1 of 1 point

 

Observations (1/2 point)

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

Tenderness (1/2 point)

•  None reported
•  Tenderness reported

 Palpated sinuses

1 of 1 point

 

Frontal (1/2 point)

•  None reported
•  Tenderness reported

Maxillary (1/2 point)

•  None reported
•  Tenderness reported

 Palpated carotid arteries

1 of 1 point

 

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Intensity (1/4 point)

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

Left: Vibration (1/4 point)

•  No thrill
•  Thrill

Left: Intensity (1/4 point)

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

 Palpated jaw

1 of 1 point

 

Observations (1/1 point)

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

 Palpated lymph nodes

1 of 1 point

 

Head And Neck (1/3 point)

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

Supraclavicular (1/3 point)

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

Axillary (1/3 point)

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

 Palpated thyroid gland

1 of 1 point

 

Observations (1/2 point)

•  No palpable abnormal findings
•  Nodules
•  Enlarged
•  Irregular

Tenderness (1/2 point)

•  None reported
•  Tenderness reported

 Auscultated carotid arteries

1 of 1 point

 

Right (1/2 point)

•  No bruit
•  Bruit

Left (1/2 point)

•  No bruit
•  Bruit

 Tested pupillary reaction

1 of 1 point

 

Observations With Penlight (1/1 point)

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

 Tested extraocular eye movements

1 of 1 point

 

Cardinal Fields (1/2 point)

•  No abnormal findings
•  Nystagmus
•  Fixed pupil

Convergence (1/2 point)

•  No abnormal findings
•  Unequal bilaterally
•  Fixed pupil

 Tested peripheral vision

1 of 1 point

 

Observations (1/1 point)

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

 Examined fundus with ophthalmoscope

1 of 1 point

 

Right: Retina (1/4 point)

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

Right: Disc Margin (1/4 point)

•  Sharp
•  Blurred

Left: Retina (1/4 point)

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

Left: Disc Margin (1/4 point)

•  Sharp
•  Blurred

 Tested visual acuity

1 of 1 point

 

Right (1/2 point)

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

Left (1/2 point)

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

 Performed whisper test

1 of 1 point

 

Right (1/2 point)

•  Normal
•  Unable to hear whispered words

Left (1/2 point)

•  Normal
•  Unable to hear whispered words

Vitals

Vitals	22:00	00:00	02:00	04:00	06:00	08:00
Temp (<38° C)	38.7 C / 101.7 F	39.1 C / 102.4 F	38.6 C / 101.5 F	37.9 C / 100.2 F	37.1 C / 98.8 F	36.7 C
BP (<120/80)		138/90	138/88	136/88	138/90	134/88
HR (60-100)		90	72	68	69	70
RR (12-20)		18	16	16	18	18
O2 Sat (>94%)		98%	98%	98%	98%	98%
Pain Scale	10	7	asleep	asleep	9	7
Pain Reassessment after Intervention	7 @23:00			asleep	5 @07:00	6

 

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