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A detailed examination report for a patient named tina jones, focusing on the head, eyes, ears, nose, and throat (heent) assessment. The report includes findings from various physical examinations, such as palpation of the sinuses, carotid arteries, jaw, lymph nodes, and thyroid gland, as well as auscultation of the carotid arteries, testing of pupillary reaction, extraocular movement, peripheral vision, and visual acuity. Additionally, the report includes information gathered from the patient through a series of questions related to headaches, vision problems, nasal and sinus issues, ear problems, mouth and throat concerns, and family medical history. The comprehensive nature of this document suggests it could be useful for medical students or healthcare professionals as a reference for heent examinations and patient assessment.
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Palapated sinuses - Answer frontal: None reported maxillary: None reported Palpated carotid arteries - Answer right vibration: No thrill right intensity: 2+ Expected left vibration: No thrill left intensity: 2+ Expected
Palpated jaw - Answer observations: No palpable abnormal findings Palpated lymph nodes - Answer head and neck: No palpable nodes supraclavicular: No palpable nodes axillary: No palpable nodes Palpated thyroid gland - Answer observations: No palpable abnormal findings tenderness: None reported Auscultated carotid arteries - Answer right: No bruit left: No bruit Tested pupillary reaction - Answer observations with penlight: No visible abnormal findings (PERRL) Tested extraocular movement - Answer cardinal fields: No abnormal findings
Asked about head problems - Answer "Do you get headaches? "Do you currently have a headache? "Other than headaches, are you experiencing head problems?" Asked about frequency of headaches - Answer "How frequently do your headaches occur?" Asked about duration of headaches - Answer "How long do your headaches last?" Asked about character and location of headaches - Answer "What do your headaches feel like?" "Where do you feel your headaches?" Asked to rate headache pain on a scale - Answer "On a scale of 1 to 10, how bad are your headaches?" Asked about headache treatment - Answer "Do you take anything to treat your headaches?"
Do you do anything to treat your headaches? What helps with your headaches? Asked about headache triggers - Answer When do you get headaches? Do your headaches coincide with your blurry vision? Asked about vision - Answer Have you been having problems with your vision? Asked about onset and frequency of blurry vision - Answer When did your vision begin worsening? When does your blurry vision occur? Have you been getting blurry vision more often? Asked about relieving factors for blurry vision - Answer What makes your blurry vision go away? Asked about vision care - Answer When was your last vision exam?
Asked about sinus problems - Answer Do you have frequent sinus congestion? Followed up on trigger of nasal problem - Answer Do your allergies trigger your runny nose? Followed up on treatment of nasal problem - Answer Are you taking any medication for your runny nose? How have you been treating your runny nose? Asked about current nasal problems - Answer Do you have a runny nose right now? Asked about alcohol intake - Answer When was your last alcoholic drink? How many alcoholic drinks do you typically have in one sitting? How many alcoholic drinks do you typically have in a week? Ask about tobacco use - Answer Do you smoke tobacco?
Do you vape? Asked about ear problems - Answer Do you have ear pain? Do you have ear discharge? Do you have vertigo? Do you use cotton swabs in your ears? Asked about hearing - Answer Have you had changes in your hearing? Do you have difficulty hearing? Inspect head and face - Answer skull symmetry: symmetric facial feature symmetry: symmetric appearance: Papules, pustules, or comedones Inspect eyes and orbital area - Answer orbital area: No visible abnormal findings
right discharge: No discharge left auditory canal color: Pink left tympanic membrane color: Pearly gray left tympanic membrane appearance: No visible abnormal findings left cone of light: 7: left discharge: No discharge Inspect mouth and throat - Answer oral mucosa: Moist and pink throat color: Pink throat texture: No abnormal findings tonsils: No visible abnormal findings post nasal drip: No discharge
Inspect neck - Answer symmetry: Symmetric appearance: Discoloration Palpated scalp - Answer observations: o additional abnormal findings tenderness: None reported Asked about mouth problems - Answer Have you had bleeding gums? Have you had mouth sores? Have you had tongue problems? Have you had dry mouth? Asked about dentition - Answer Do you have current dental problems? When was your last dental visit?
Asked family history of eye problems - Answer Do you have a family history of eye problems? Asked family history of ear problems - Answer Do ear problems run in your family? Do you have a family history of hearing loss? Asked family history of nasal problems - Answer Has anyone in your family had hay fever? Asked family history of mouth problems - Answer Do mouth problems run in your family? Do you have a family history of dental problems? Do you have a family history of mouth cancer? Asked family history of throat and surrounding gland problems - Answer Do thyroid problems run in your family? Do you have a family history of lymph node cancers?
Do you have a family history of throat cancer?
