NUR 634 Tina Jones HEENT Complete Solution
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Hover over the Patient Data items below to reveal important information, including Pro
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• Found:
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• Available:
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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: 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:
Is your throat sore?
•
Finding:
Reports itchy throat
(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:
Is your throat itchy?
•
Finding:
Reports itchy eyes
(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:
Are your eyes itchy?
•
Finding:
Reports 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?
History of Present Illness
•
Finding:
Asked about onset of symptoms
•
Finding:
Reports sore throat began "about a week ago"
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina's throat has been sore will also aid in treating her sore throat.
Example Question:
How long has your throat been sore?
•
Finding:
Reports runny nose began "about a week ago"
(Found)
Pro Tip: Establishing a timeline for how long Tina's nose has been running will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
When did your nose start running?
•
Finding:
Reports itchy eyes began "about a week ago"
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina's eyes have been itching will also aid in treating her itchy eyes.
Example Question:
When did your eyes start itching?
•
Finding:
Asked about aggravating factors for throat symptoms
•
Finding:
Reports throat pain is constant
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina's throat has been sore will also aid in treating her sore throat.
Example Question:
Is the throat pain constant?
•
Finding:
Reports throat pain is worse in the morning
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina's throat has been sore will also aid in treating her sore throat.
Example Question:
When does your sore throat feel the worst?
•
Finding:
Reports some soreness with swallowing
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Does it hurt when you swallow?
•
Finding:
Asked severity of throat discomfort
•
Finding:
Describes sore throat as mild to moderate
(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:
Can you rate your sore throat on a scale of 0 to 10?
•
Finding:
Asked about frequency and duration of runny nose
•
Finding:
Reports nose is runny "pretty much all day"
(Found)
Pro Tip: Establishing a timeline for how long Tina's nose has been running will illustrate how long she has been suffering these particular symptoms, when the symptoms are worst, and possible triggers.
Example Question:
How often does your nose run?
•
Finding:
Asked about character of nasal symptoms
•
Finding:
Denies itchy nose
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Does your nose itch?
•
Finding:
Denies sinus pain
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Do you feel any sinus pain?
•
Finding:
Denies sinus pressure
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Do you feel any sinus pressure?
•
Finding:
Denies sneezing
(Available)
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:
Have you been sneezing?
•
Finding:
Followed up about character of nasal discharge
•
Finding:
Reports clear discharge
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
What color is your mucus?
•
Finding:
Reports thin discharge
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Is the mucus thick?
•
Finding:
Denies purulent discharge
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Does your mucus have pus in it?
•
Finding:
Asked about eye symptoms
•
Finding:
Reports eye itching is constant
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Determining when Tina's eyes most itch will also aid in treating her itchy eyes.
Example Question:
Do your eyes constantly itch?
•
Finding:
Reports eye redness
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Are your eyes red?
•
Finding:
Asked related respiratory symptoms
•
Finding:
Reports breathing isn't affected
(Found)
Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tina's current condition and previous breathing concerns or conditions.
Example Question:
Have you had any changes in your breathing?
•
Finding:
Denies cough
(Available)
Pro Tip: A shallow history of a patient's condition can provide a comparative baseline for juxtaposing an attack, exacerbation, and more regular breathing. Soliciting this information from Tina allows her to explain any recent developments with her asthma.
Example Question:
Do you have a cough?
•
Finding:
Denies chest tightness
(Available)
Pro Tip: For many patients with asthma, exacerbation often results in chest tightness. Asking Tina if her chest feels tight might point to possible asthma symptoms.
Example Question:
Does your chest feel tight?
•
Finding:
Asked about related asthma symptoms
•
Finding:
Denies recent wheezing
(Available)
Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and thus might not volunteer this information. Asking Tina whether she has been wheezing illustrates how her asthma is presenting.
Example Question:
Have you been wheezing?
•
Finding:
Denies increase in recent asthma symptoms
(Found)
Pro Tip: Discerning what's making Tina's asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina's breathing.
Example Question:
Has your asthma been worse lately?
•
Finding:
Asked about exposure to allergens
•
Finding:
Reports no exposure to cats
(Found)
Pro Tip: Tina's symptoms are consistent with being exposed to allergens. Asking Tina if she's recently been exposed to allergens could explain what's triggering her symptoms.
Example Question:
Have you been recently exposed to any allergens?
•
Finding:
Reports no exposure to mold or mildew
(Available)
Pro Tip: Exposure to mold can result in painful ear, nose, or throat symptoms. Asking Tina if she has mold in her house might indicate a possible trigger that she has been exposed to.
Example Question:
Do you have mold in your house?
•
Finding:
Reports no exposure to dust
(Found)
Pro Tip: Exposure to dust can result in painful ear, nose, or throat symptoms. Asking Tina if she has dust in her house might indicate a possible trigger that she has been exposed to.
Example Question:
Do you have dust in your house?
•
Finding:
Reports no known exposure to irritants in work environment
(Available)
Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation.
Example Question:
Are you allergic to anything at work?
•
Finding:
Reports changing bedding "once a week"
(Available)
Pro Tip: Bedding provides the perfect environment for dust mites and other allergens. By asking Tina if she regularly changes her bedding, you're soliciting information about environmental factors that might exacerbate her condition.
Example Question:
How often do you change your bedding?
•
Finding:
Asked about perceived cause of symptoms
•
Finding:
Describes symptoms as similar to allergies
(Found)
Pro Tip: Questions about what factors might have caused certain symptoms can point to a patient's environmental stressors, habits, and general wellbeing. Asking Tina what caused her asthma might indicate her health literacy and understanding of what factors impact her breathing.
Example Question:
Do you know what's causing your symptoms?
•
Finding:
Reports that the symptoms don't seem like a common cold
(Found)
Pro Tip: A patient is an expert on her body. Asking Tina if she thinks she has a cold will give Tina the opportunity to compare her current symptoms with cold symptoms she's historically had and describe if her current symptoms differ from those she experiences when she has a cold.
Example Question:
Do you think you have a cold? [Show Less]