HEENT Tina Jones Transcript and Documentation – assignmenthandlers

Do you have headaches?

Question
07/21/22 1:50 AM MDT

Yeah, I get them a lot when I’m studying.

How frequently do the headaches occur?

Question
07/21/22 1:51 AM MDT

Maybe once a week? I usually do a lot of my school work at once, so I’ll study for like, 5 or 6 hours. I usually end up with a headache by the end of the night.

How long do your headaches last?

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07/21/22 1:51 AM MDT

A few hours, I guess. I usually take some Tylenol and then go to bed to get rid of them.

How do the headaches feel like?

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07/21/22 1:52 AM MDT

When I get them, the pain is sort of… tight and throbbing, I guess.

HEENT Tina Jones Transcript and Documentation On a scale of 1 to 10 how bad are your headaches?

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07/21/22 1:52 AM MDT

Not too bad. . . I’d say about 3. Or a 4 if I really push it.

What triggers the headache?

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07/21/22 1:53 AM MDT

When I get headaches, it’s usually just from reading. I only get them about once a week and it doesn’t really hurt on one side or the other. The pain is mostly behind both eyes.

Do you have any vision problem?

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07/21/22 1:56 AM MDT

Yeah, maybe so. I’ve noticed my vision getting sort of blurry when I read. It seems like it’s getting a little worse — I notice it more.

When did your vision start worsening?

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07/21/22 1:57 AM MDT

I’m not sure — Maybe over the last year or so.

Are you able to swallow?

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07/22/22 2:01 AM MDT

Um, yeah.

Is there throat pain while swallowing?

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07/22/22 2:01 AM MDT

Yes, it hurts my throat to swallow.

What is the rate of throat pain on a scale of 1-10?

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07/22/22 2:02 AM MDT

It’s like a 4 out of 10, maybe.

Have you taken any treatment at home? (Clarified to Have you tried treatments at home?.)

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07/22/22 2:02 AM MDT

All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps. (Clarified to if I have tried treatments at home.)

Have you taken any OTC medication?

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07/22/22 2:02 AM MDT

I’ve been using throat drops, like lozenges, for my sore throat. Other than that, I just have my inhaler.

Do you have eye pain?

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07/22/22 2:03 AM MDT

No, my eyes don’t hurt. They’re just itchy.

Do you use glasses or contacts?

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07/22/22 2:03 AM MDT

No, I’ve never had glasses or contacts.

Does the OTC medication improve the pain? (No matching questions found.)

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07/22/22 2:04 AM MDT

Does the OTC medication help? (No matching questions found.)

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07/22/22 2:04 AM MDT

What other medical problem do you have? HEENT Tina Jones Transcript and Documentation

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07/22/22 2:05 AM MDT

Um, the only things I know I’m diagnosed with are diabetes. And asthma.

When were you diagnosed with diabetes?

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07/22/22 2:05 AM MDT

I was diagnosed when I was 24.

 Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported

Exam Action
07/22/22 2:06 AM MDT

 Palpated frontal sinuses: No tenderness reported

Exam Action
07/22/22 2:06 AM MDT

 Palpated maxillary sinuses: No tenderness reported

Exam Action
07/22/22 2:07 AM MDT

Where is the location of headache?

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07/22/22 2:07 AM MDT

It’s kind of behind my forehead.

Do you take anything to treat your headaches?

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07/22/22 2:09 AM MDT

Yeah. Usually I’ll take a Tylenol and go to bed, and that’ll get rid of it.

What triggers your headaches?

Question
07/22/22 2:09 AM MDT

When I get headaches, it’s usually just from reading. I only get them about once a week and it doesn’t really hurt on one side or the other. The pain is mostly behind both eyes.

When did your vision begin worsening?

Question
07/22/22 2:09 AM MDT

I’m not sure — Maybe over the last year or so.

What makes your blurry vision go away?

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07/22/22 2:10 AM MDT

If I stop reading and rest my eyes a bit, then it clears up.

When was your last vision exam?

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07/22/22 2:10 AM MDT

I must’ve been… maybe ten the last time the school nurse checked my vision. You know how the school nurses do those little checks every year.

Do you have any allergies?

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07/22/22 2:10 AM MDT

Yeah. I’m allergic to cats. And dust, too.

What triggers the eye symptoms? (Clarified to What triggers your symptoms?.)

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07/22/22 2:12 AM MDT

It’s a little worse in the morning, but that’s really the only pattern I’ve noticed. (Clarified to what triggers my symptoms.)

Are you taking medication for the itchy eyes?

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07/22/22 2:15 AM MDT

No, I haven’t done anything to try to make my eyes less itchy.

Do you have general nose problems?

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07/22/22 2:15 AM MDT

Yes, my nose won’t stop running!

Have you had nosebleeds? HEENT Tina Jones Transcript and Documentation

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07/22/22 2:18 AM MDT

No.

Do you have frequent sinus congestion? (Clarified to Do you have sinus congestion?.)

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07/22/22 2:18 AM MDT

No, I’m not stuffed up — my nose has been running nonstop! (Clarified to if I have sinus congestion.)

Do your allergies trigger your runny nose?

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07/22/22 2:19 AM MDT