HEENT | Completed | Shadow Health
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HEENT Results | Turned In
Advanced Health Assessment - Clinical Replacement, NURS 520
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HEENT | Completed | Shadow Health
https://app.shadowhealth.com/assignment_attempts/6391605 1/17
HEENT Results | Turned In
Advanced Health Assessment - Clinical Replacement, NURS 520
Return to Assignment (/assignments/316001/)
Transcript
Started: Mar 27, 2020 | Total Time: 82 min
Gree
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Empathize
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Your Results Lab Pass (/assignment_attempts/6391605/lab_pass.p
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Interview Questions (119) Statements (12) Exam Actions (72)
Hello Miss Jones I'm Amor, an NP student. I will be interviewing you and examining you today.
Is that ok
Hey.
What brings you in today
My throat has been sore... and itchy. And my nose won't stop running. These symptoms are
driving me nuts.
I'm sorry to hear that you are not feeling well today. Let us see what we can do to help these
symptoms improve
Thanks for saying that.
Miss Jones what is your birth date (Clarified to What is the date of your birth?.)
February 17th. (Clarified to what is my birth date.)
How old are you
I'm 28.
How long have you had these symptoms
My itchy eyes, runny nose, and sore throat all started a week ago. [AUDIO COMING SOON]
Have you had this problem before (Clarified to Have you had these symptoms before?.)
Well, no. I mean, I never had allergies to pollen or anything outdoors like that. . . But my nose
is acting just like my sister's right now, and she's always had hay fever. I'm starting to think that
this is allergies. (Clarified to if I have had these symptoms before.)
How severe is your sore throat
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4/4/2020 HEENT | Completed | Shadow Health
https://app.shadowhealth.com/assignment_attempts/6391605 2/17
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It's not... terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won't
go away.
On a scale of 1 to 10 how severe is the sore throat
Like, if zero is no itch and ten is 'I can't stand it,' I'd say it's a 5.
Have you ever had this problem before (Clarified to Have you had these symptoms before?.)
Well, no. I mean, I never had allergies to pollen or anything outdoors like that. . . But my nose
is acting just like my sister's right now, and she's always had hay fever. I'm starting to think that
this is allergies. (Clarified to if I have had these symptoms before.)
Is too sore throat pain constant
Yeah, it's sore pretty much all the time.
Can you describe the sore throat pain (Clarified to What is your throat pain like?.)
I don't know how I would describe it, other than "sore." (Clarified to what my throat pain is like.)
On a scale of 1 to 10 how would you rate the sore throat pain (Clarified to How would you rate
your sore throat on a scale from 0 to 10?.)
Like, if zero is no itch and ten is 'I can't stand it,' I'd say it's a 5. (Clarified to to rate my sore
throat.)
Does the pain radiate
No, it's just in my throat.
Does anything make your sore throat feel better
All I've done is suck on some throat drops. And I've been drinking more water, which helps.
That is very good, Drinking water prevents throat dryness
OK, I understand.
Does anything make the throat pain worse
Well, my throat's usually worse in the mornings, and swallowing can make it sore, too. [AUDIO
COMING SOON]
Do you have any other symptoms associated with sore throat (Clarified to Do you have any
other symptoms?.)
Let's see... I have alot going on so here's the laundry list: sore and itchy throat, runny nose,
itchy eyes. (Clarified to if I have other symptoms.)
4/4/2020 HEENT | Completed | Shadow Health
https://app.shadowhealth.com/assignment_attempts/6391605 3/17
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Do you have any nasal discharges
Yes, it won't stop running!
What's the color of your nasal discharge
It's just clear.
Do you feel nasally congested
No, I'm not stuffed up -- my nose has been running nonstop!
Do you have any eye symptoms
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.
Have you been exposed to any allergens
Not lately.
Do you have any family history of throat problems
No.
You taking any over-the-counter medications for your symptoms
I just use my inhaler.
Name of your inhaler
It's just a regular Proventil inhaler.
Do you remember the dose of your inhaler
I think it says to do 2 puffs.
Often have you been using your inhaler (Clarified to Have you been using your inhaler more?.)
No, no more than usual. (Clarified to if I have been using my inhaler more.)
How often do you use your inhaler
I don't use it every day -- maybe I use it 2 or 3 times a week. Sometimes not at all.
4/4/2020 HEENT | Completed | Shadow Health
https://app.shadowhealth.com/assignment_attempts/6391605 4/17
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Do you take other over-the-counter medications other than Proventil
I've been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or
Advil for cramps, but not often.
Thanks for telling me. It is important to keep me updated on all medications that you take, even
over the counter drugs. Medications can interact with each other and can be toxic
Thanks for telling me.
Often do you use your inhaler
I don't use it every day. I used it last week, I think.
Do you have asthma
Yeah, I do.
Can you describe your asthma symptoms
My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get
enough air into my lungs.
How severe your asthma symptoms (Clarified to How severe is your asthma?.)
My asthma has been pretty under control. I use my inhaler a few times a week and it helps.
(Clarified to how severe my asthma is.)
Have you been hospitalized before
I used to go to the hospital for asthma growing up, but I hadn't been in a while until about a
month ago. . . I had to go to the ER for my foot.
When was the last time you were hospitalized with asthma (Clarified to When was your last
hospitalization for asthma?.)
I used to go to the hospital alot, for asthma attacks, but not since I was sixteen. (Clarified to
when my last hospitalization for asthma was.)
Why do you go last message to the hospital
I had to go to the ER a little over a month ago for my foot. . . before that, I hadn't gone since I
was sixteen.
Tell me more what happened in your foot last month (No matching questions found.)
what happened to your foot last month
I scraped it up pretty bad a while ago. It got infected, too. [AUDIO COMING SOON]
4/4/2020 HEENT | Completed | Shadow Health
https://app.shadowhealth.com/assignment_attempts/6391605 5/17
Empathize
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I am glad to hear that your foot is getting better
Thanks for understanding.
Do you have any allergies
Yeah. I'm allergic to cats. And dust, too.
What do you use to improve your eye symptoms
All I've done is suck on some throat drops. And I've been drinking more water, which helps.
Does anything help with your itchy eyes
No, I haven't done anything to try to make my eyes less it
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