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Tina Jones HEENT Subjective.pdf

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10/24/2020
HEENT | Completed | Shadow Health
HEENT Results | Turned In
Health Assessment - Fall 2020, NUR 310
Return to Assignment (/assignments/366635/)
Your Results
Overview
Lab Pass (/assignment_attempts/7939000/lab_pass.pd
Subjective Data Collection: 34 of 34 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal...
Indicates an item that you
found.
Hover over the Patient Data items
below to reveal important
information, including Pro Tips and
Example Questions.
Indicates an item that is
available to be found.
Objective Data Collection
Documentation
Hallway
Lifespan
Review Questions
Self-Reflection
Category
Scored Items
Patient Data
Not Scored
Experts selected these topics as essential components
of a strong, thorough interview with this patient.
A combination of open and closed questions will yield
better patient data. The following details are facts of t
patient's case.
Relevant Medical History
Asked about head problems
Reports occasional headaches
Denies current headache
Denies head problems other than headaches
Asked about frequency of headaches
Reports headaches occur once a week
Asked about duration of headaches
Reports headaches last a few hours
Asked about character and location of
headaches
Asked to rate headache pain on a scale
Asked about headache treatment
Reports headaches as tight and throbbing
Reports headache located behind her eyes
Reports headaches as a 2/10 or 3/10
Reports treating headaches with acetaminophen
(Tylenol)
Reports resting to treat headache
Reports acetaminophen (Tylenol) and rest usually
resolve symptoms
Asked about headache triggers
Reports headaches only happen when reading or
studying
Reports that blurry vision and headaches often
coincide
Asked about vision
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Reports occasional blurry vision
Support
1/4
10/24/2020
HEENT | Completed | Shadow Health
Asked about onset and frequency of blurry vision
Reports worsening vision began within the past
year
Reports blurry vision only occurs when reading for
long periods
Reports noticing blurry vision increasing in the
past few months
Asked about relieving factors for blurry vision
Reports that resting eyes helps
Asked about vision care
Reports last vision exam was in childhood
Denies use of corrective lenses
Asked about additional eye problems
Reports occasional itchy eyes
Reports occasional eye redness
Denies eye pain
Denies eye dryness
Asked about triggers for eye symptoms
Reports cat allergy is a trigger for itchy eyes
Reports dust is a trigger for itchy eyes
Asked about treatment of eye symptoms
Denies taking medication for itchy eyes
Asked about nasal problems
Reports occasional runny nose
Denies nosebleeds
Asked about sinus problems
Denies frequent sinus problems
Followed up on trigger of nasal problem
Reports cat allergy is trigger for runny nose
Followed up on treatment of nasal problem
Denies taking medication for runny nose
Reports treatment is avoiding trigger
Reports treatment is showering
Asked about current nasal problems
Denies current runny nose
Asked about alcohol intake
Reports last alcoholic drink was 3 weeks ago
Risk Factors
Reports no more than 2 or 3 alcoholic drinks in
one sitting
Reports no more than 1 or 2 nights a week
drinking alcohol
Asked about tobacco use
Denies tobacco use
Denies vaping
Review of Systems
Asked about ear problems
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Denies ear pain
Denies ear discharge
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10/24/2020
HEENT | Completed | Shadow Health
Denies vertigo
Reports using cotton swabs in ears weekly
Asked about hearing
Denies hearing changes
Denies difficulty hearing
Asked about mouth problems
Denies bleeding gums
Denies mouth sores
Denies tongue problems
Denies dry mouth
Asked about dentition
Denies current dental problems
Reports visit within the last 2 years
Reports regular visits in childhood
Reports only having a few cavities in childhood
Reports flossing
Asked about throat problems
Denies sore throat
Denies voice changes
Denies difficulty swallowing
Asked about lymph node problems
Denies painful lymph nodes
Denies swollen lymph nodes
Asked about thyroid problems
Denies thyroid problems
Asked family history of head problems
Denies family history of head problems
Asked family history of eye problems
Denies family history of eye problems
Asked family history of ear problems
Denies family history of ear problems
Relevant Family History
Denies family history of hearing loss
Asked family history of nasal problems
Reports sister has regular hay fever
Asked family history of mouth problems
Denies family history of general mouth problems
Denies family history of mouth cancer
Denies family history of dental problems
Asked family history of throat and surrounding
gland problems
Denies family history of thyroid problems
Denies family history of lymph node cancers
Denies family history of throat cancer
Comments
Barbara Morey (16 Oct 2020, 09:21 PM EDT):
This study source was downloaded by 100000799851538 from CourseHero.com on 09-18-2023 14:13:34 GMT -05:00
https://app.shadowhealth.com/assignment_attempts/7939000
https://www.coursehero.com/file/71370430/Tina-Jones-HEENT-Subjectivepdf/
3/4
10/24/2020
HEENT | Completed | Shadow Health
Amanda, you did very well in this assignment in the subjective and data collection section. Please note that your are to do all section for you did not do the progress notes for the second tim
This is part of the assignment. If this is not done in future assignments points will be taken off the final grade for the assignment and this is what will be noted in Blackboard. Did well in all th
st of the sections.
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https://app.shadowhealth.com/assignment_attempts/7939000
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