HEENT
ME: hi my name is Sedra I will be your nurse for today, before we start,
I will just wash my hands.
ME: Patient appears to be sitting comfortably
ME: can you please state your name…. date of birth…. And date. (
Patient is AAOx3)
ME: can you please tell me what brings you in today?
Person: I have been having bad ear pain
ME: when was the onset of this ear pain
ME: can you show me the location of your pain
Person: yes, it is in my right ear
ME: does the pain radiate anywhere else besides your ear
Person: no
ME: how long have you been having ear pain
Person: 3 days
ME: can you explain to me the type of pain you are having for an
example is it sharp is it dull?
Person: it is a sharp pain
ME: is there anything that makes the pain better or worse:
Person: no
ME: is there a specific time you feel this ear pain or is it constant?
Person: it is constant
ME: on a scale of 0-10 with 0 being no pain and 10 being the worst pain
you’ve ever felt how would you rate your pain right now
Person: a 5
ME: performs regular vital signs ( BP, TEMP, PULSE,
RESPIRATIONS, APICAL PULSE).
ME: patient is able to speak in full sentences and appears to be groomed
well, patient is active and has no trouble walking or moving from bed to
chair.
ME: patient appears to be well hydrated, skin is not dry, and they have
normal color.
ME: when was the last time you passed stool ?
ME: when was the last time you peed?
ME: when was the last time you had something to eat?
HEAD and FACE:
Right now I am just going to palpate your facial bones (
I am going to check for TMJ
Palapte your sinuses (