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Tina Jones HEENT Shadow Health Objective Data Collection
Introduction:
The Head, Eyes, Ears, Nose, and Throat (HEENT) examination is a critical component of a comprehensive health assessment. In this essay, we will delve into the objective data collected during Tina Jones’s HEENT examination, analyzing each component and its implications for her overall health.
Head and Face Inspection:
Beginning with the inspection of the head and face, we assessed the symmetry of Tina’s skull and facial features. Symmetry is a key indicator of normal development and function. Fortunately, Tina displayed symmetry in both aspects, suggesting a healthy cranial and facial structure. Additionally, we observed the general appearance, looking for any visible abnormalities, such as rashes or skin growths. This initial inspection sets the foundation for further examination.
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NURS 6512 Building a Health History: Adolescent Hispanic/Latino boy living in a middle-class suburb
Eyes and Orbital Area Examination:
Moving on to the eyes and orbital area, we thoroughly examined Tina’s ocular health. The assessment included the orbital area, sclera, conjunctiva, and conjunctival discharge. A comprehensive evaluation revealed no abnormalities in Tina’s orbital region. Her sclera exhibited a normal white appearance, and the conjunctiva appeared moist and pink without any signs of discharge. This portion of the examination provides insights into potential eye infections or allergic reactions.
Nasal Cavity Inspection:
The inspection of Tina’s nasal cavities involved an assessment of color, discharge, turbinate patency, and additional observations. Our findings indicated a pink color, no discharge, and patent turbinates, suggesting a healthy nasal passage. This examination is crucial for identifying potential respiratory issues or sinus infections.
Ear Examination:
Moving on to the ears, our assessment included the auditory canal color, tympanic membrane color, appearance, cone of light, and discharge. Tina’s ears exhibited a pearly gray tympanic membrane, normal cone of light, and no signs of discharge, indicating healthy ear function. This examination provides valuable information about potential ear infections or hearing issues.
Mouth and Throat Inspection:
The examination of Tina’s mouth and throat encompassed the oral mucosa, tonsils, posterior oropharynx, post-nasal drip, and neck inspection. Our findings revealed moist and pink oral mucosa, normal tonsils, and a slightly erythematous posterior oropharynx. These observations contribute to the assessment of Tina’s respiratory and gastrointestinal health.
Neck Examination:
The neck examination involved symmetry, appearance, palpation of the scalp, sinuses, temporal arteries, carotid arteries, jaw, and lymph nodes. Symmetry and the absence of abnormalities in these areas are indicative of normal neck function. Palpation revealed no tenderness, masses, or abnormalities. This part of the assessment provides insights into potential issues related to the lymphatic system, blood vessels, and musculoskeletal structure.
Conclusion:
In conclusion, the HEENT examination conducted on Tina Jones yielded valuable objective data about her head, eyes, ears, nose, and throat. Each component of the assessment contributes to a comprehensive understanding of Tina’s overall health. The findings will guide further investigations and interventions to ensure her well-being. This essay emphasizes the importance of a systematic and thorough HEENT examination in providing a holistic view of a patient’s health status.
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Tina Jones HEENT Shadow Health Objective Data Collection
- Correct
- Partially correct
- Incorrect
- Missed
Inspected head and face
0.67 of 1 point
Skull Symmetry (1/3 point)
- Symmetric
- Asymmetric
Facial Feature Symmetry (1/3 point)
- Symmetric
- Asymmetric
Appearance (No point)
- No visible abnormal findings
- Rash
- Papules, pustules, or comedones
- Skin growths (freckles, moles, or birthmarks)
- Excessive hair growth
- Evidence of skin trauma (scar, laceration, or bruising)
- Red, chapped nose
Inspected eyes and orbital area
1 of 1 point
Orbital Area (1/4 point)
- No visible abnormal findings
- Ptosis
- Eyelid edema
- Lesion
- Allergic shiners
Sclera (1/4 point)
- White
- Injection
- Icterus
Conjunctiva (1/4 point)
- Moist and pink
- Pale
- Dry appearance
- Erythema
- Edema
Conjunctival Discharge (1/4 point)
- No discharge
- Clear, watery discharge
- Purulent discharge
Inspected nasal cavities
0.75 of 1 point
Color (No point)
- Pink
- Pale
- Erythemic
- Bluish
Discharge (1/4 point)
- No discharge
- Clear discharge
- Bloody discharge
- Purulent discharge
Turbinate Patency (1/4 point)
- Patent
- Decreased patency
- Not patent
Observations (1/4 point)
- No additional visible abnormal findings
- Foreign body present
- Polyp
- Septum perforated
- Septum deviated
- Lesion
Inspected ears
1 of 1 point
Right: Auditory Canal Color (1/10 point)
- Pink
- Red
- Pallor
Right: Tympanic Membrane Color (1/10 point)
- Pearly gray
- Red
- Opaque
- Yellow
- Not visible because of cerumen
Right: Tympanic Membrane Appearance (1/10 point)
- No visible abnormal findings
- Fluid observed
- Visible scars
- Bulging
- Perforation
- Retraction
Right: Cone Of Light (1/10 point)
- 5:00
- Cone of light distorted
Right: Discharge (1/10 point)
- No discharge
- Cerumen
- Clear discharge
- Bloody discharge
- Purulent discharge
Left: Auditory Canal Color (1/10 point)
- Pink
- Red
- Pallor
Left: Tympanic Membrane Color (1/10 point)
- Pearly gray
- Red
- Opaque
- Yellow
- Not visible because of cerumen
Left: Tympanic Membrane Appearance (1/10 point)
- No visible abnormal findings
- Fluid observed
- Visible scars
- Bulging
- Perforation
- Retraction
Left: Cone Of Light (1/10 point)
- 7:00
- Cone of light distorted
Left: Discharge (1/10 point)
- No discharge
- Cerumen
- Clear discharge
- Bloody discharge
- Purulent discharge
Inspected mouth and throat
1 of 1 point
Oral Mucosa (1/6 point)
- Moist and pink
- Dry appearance
- Erythemic
Tonsils (1/6 point)
- No visible abnormal findings
- Edema
- Erythema
Tonsil Grade (1/6 point)
- 0: Tonsils fit within tonsillar fossa
- 1+: Tonsils <25% of space between pillars
- 2+: Tonsils <50% of space between pillars
- 3+: Tonsils <75% of space between pillars
- 4+: Tonsils >75% of space between pillars
Posterior Oropharynx Color (1/6 point)
- Pink
- Erythemic
Posterior Oropharynx Texture (1/6 point)
- No abnormal findings
- Cobblestoning
- Exudate
Post Nasal Drip (1/6 point)
- No discharge
- Clear discharge
- Purulent discharge
Inspected neck
1 of 1 point
Symmetry (1/2 point)
- Symmetric
- Asymmetric
Appearance (1/2 point)
- No visible abnormal findings
- Swelling
- Visible pulsation
- Visible mass
- Discoloration
Palpated scalp
1 of 1 point
Tenderness (1/2 point)
- None reported
- Tenderness reported
Observations (1/2 point)
- No additional abnormal findings
- Balding or thinning areas in hair distribution
- Palpable masses
Palpated sinuses
1 of 1 point
Frontal (1/2 point)
- None reported
- Tenderness reported
Maxillary (1/2 point)
- None reported
- Tenderness reported
Palpated temporal arteries
1 of 1 point
Right: Vibration (1/4 point)
- No thrill
- Thrill
Right: Intensity (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Left: Vibration (1/4 point)
- No thrill
- Thrill
Left: Intensity (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Palpated carotid arteries
1 of 1 point
Right: Vibration (1/4 point)
- No thrill
- Thrill
Right: Intensity (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Left: Vibration (1/4 point)
- No thrill
- Thrill
Left: Intensity (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Palpated jaw
1 of 1 point
Observations (1/1 point)
- No palpable abnormal findings
- Limited range of motion
- Popping or clicking
Palpated lymph nodes
1 of 1 point
Head And Neck (1/3 point)
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
Supraclavicular (1/3 point)
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
Axillary (1/3 point)
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
Palpated thyroid gland
1 of 1 point
Observations (1/2 point)
- No palpable abnormal findings
- Nodules
- Enlarged
- Irregular
Tenderness (1/2 point)
- None reported
- Tenderness reported
Auscultated breath sounds
1 of 1 point
Breath Sounds (1/3 point)
- Present in all areas
- Diminished in some areas
- Absent in some areas
Adventitious Sounds (1/3 point)
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
Location (1/3 point)
- All areas clear
- Adventitious sounds in anterior right upper lobe
- Adventitious sounds in anterior right middle lobe
- Adventitious sounds in anterior right lower lobe
- Adventitious sounds in anterior left upper lobe
- Adventitious sounds in anterior left lower lobe
- Adventitious sounds in posterior right upper lobe
- Adventitious sounds in posterior right lower lobe
- Adventitious sounds in posterior left upper lobe
- Adventitious sounds in posterior left lower lobe
Auscultated temporal arteries
1 of 1 point
Right (1/2 point)
- No bruit
- Bruit
Left (1/2 point)
- No bruit
- Bruit
Auscultated carotid arteries
1 of 1 point
Right (1/2 point)
- No bruit
- Bruit
Left (1/2 point)
- No bruit
- Bruit
Tested pupillary reaction
1 of 1 point
Observations With Penlight (1/1 point)
- No visible abnormal findings (PERRL)
- Unequal
- Irregular
- Miosis
- Mydriasis
- Non-reactive to light
Tested extraocular eye movements
1 of 1 point
Cardinal Fields (1/2 point)
- No visible abnormal findings
- Nystagmus
- Fixed pupil
Convergence (1/2 point)
- No visible abnormal findings
- Unequal bilaterally
- Fixed pupil
Tested peripheral vision
1 of 1 point
Observations (1/1 point)
- No abnormal findings
- Reduced right visual field
- Reduced left visual field
Examined fundus with ophthalmoscope
1 of 1 point
Right: Retina (1/4 point)
- No visible abnormal findings
- Myelinated nerve fibers
- Papilledema
- Glaucomatous cupping
- Drusen bodies
- Cotton wool bodies
- Hemorrhage
Right: Disc Margin (1/4 point)
- Sharp
- Blurred
Left: Retina (1/4 point)
- No visible abnormal findings
- Myelinated nerve fibers
- Papilledema
- Glaucomatous cupping
- Drusen bodies
- Cotton wool bodies
- Hemorrhage
Left: Disc Margin (1/4 point)
- Sharp
- Blurred
Tested visual acuity
1 of 1 point
Right (1/2 point)
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
Left (1/2 point)
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
Performed Weber test
1 of 1 point
Results (1/1 point)
- Normal
- Conductive or sensorineural loss
Performed Rinne test
1 of 1 point
Right (1/2 point)
- Normal
- Conductive loss
Left (1/2 point)
- Normal
- Conductive loss
Performed whisper test
1 of 1 point
Right (1/2 point)
- Normal
- Unable to hear whispered words
Left (1/2 point)
- Normal
- Unable to hear whispered words
Tested gag reflex
1 of 1 point
Observations (1/1 point)
- Intact
- Absent
- Hypersensitive