Health History Tina Jones Shadow health Transcript
Transcript
Started: May 24, 2020 | Total Time:350 min
 |
Height: 170 cm
|
Exam Action |
|
Weight: 90 kg
|
Exam Action |
|
BMI: 31
|
Exam Action |
|
Random blood glucose: 238
|
Exam Action |
|
Temperature: 101.1 F
|
Exam Action |
|
Blood pressure: 142/82
|
Exam Action |
|
Respiratory rate: 19
|
Exam Action |
|
O2 sat: 99%
|
Exam Action |
|
Heart rate: 86
|
Exam Action |
|
Hello. My name is Joan and I will be interviewing you today and later examine you.
|
Greet |
 |
Hey.
|
|
|
What is your name?
|
Question |
|
Tina Jones.
|
|
|
Why are you here today?
|
Question |
|
I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!
|
|
|
Am sorry to hear that?
|
Empathize |
|
I appreciate you saying that.
|
|
|
When did you get the scrape?
|
Question |
|
Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
|
|
|
How severe is the pain?
|
Question |
|
It’s really bad.
|
|
|
Can you describe the pain?
|
Question |
|
It’s throbbing and like, sharp if I try to put weight on it.
|
|
|
Did you hurt any other part?
|
Question |
|
No, I caught myself on the railing so I didn’t fall on the ground. Only my foot got hurt.
|
|
|
how has the pain changed over time?
|
Question |
|
At first, it seemed like it was healing up fine and it didn’t give me a lot of pain. But the last two days, the pain got way worse.
|
|
|
Does the pain radiate anywhere else?
|
Question |
|
The pain’s worse in my foot, but I feel it moving up into my ankle, too.
|
|
|
How painful is the ankle? (Clarified to How did you hurt your ankle?.)
|
Question |
|
I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step. (Clarified to how I hurt my ankle.)
|
|
|
is it possible for you to stand on your foot?
|
Question |
|
No, I can’t put weight on my foot without really sharp pain.
|
|
|
How do yo rate the pain on a scale of 0 o 10 (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)
|
Question |
|
I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet. (Clarified to how I would rate my pain on a scale.)
|
|
|
can you tell me where the pain is located?
|
Question |
|
It feels like the pain is just centered around the scrape, like around the ball of my foot. That’s where it hurts the most, but my whole foot feels some pain.
|
|
|
Which foot did you injure?
|
Question |
|
My right foot.
|
|
|
Were you wearing shoes?
|
Question |
|
||
WE GUARANTEE A DCE SCORE OF ABOVE 95% AND HANDLE THE SOAP NOTE |
||
|
Seems you love your work
|
Empathize |
|
|
Thanks for saying that.
|
|
|
Do you have other health problems?
|
Question |
|
Um, the only things I know I’m diagnosed with are diabetes. And asthma.
|
|
|
When were you diagnosed with asthma?
|
Question |
|
My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.
|
|
|
when dod you last have an asthma attack (Clarified to When was your last asthma attack?.)
|
Question |
|
It’s really rare for me to have an attack now. Three days ago I had some breathing problems, but I guess probably my last full attack was in high school. (Clarified to when my last asthma attack was.)
|
|
|
How was your asthma when you were in high school?
|
Question |
|
I was always a pretty average student. . . never the best, never the worst.
|
|
|
how do you know when you have asthma attack? (Clarified to What happens when you have an asthma attack?.)
|
Question |
|
I haven’t had an asthma attack in a while, but I used to get them growing up, and my chest would feel really tight, like I couldn’t take in air, and I would wheeze really bad and get all sweaty. It was way worse than now, especially because I would use my inhaler and it wouldn’t help. It was really scary. (Clarified to to tell you about my asthma attacks.)
|
|
|
Do you get tight chest?
|
Question |
|
Well. . . when my asthma gets bad my chest feels pretty tight, like I can’t take in air.
|
|
|
Do you get breathing difficult? (No matching questions found.)
|
Question |
|
Do you get breathing difficulties during asthma attacks?
|
Question |
|
I haven’t had a full attack in years, but when my breathing gets bad, I just use my inhaler.
|
|
|
What about wheezing? (Clarified to How is your wheezing?.)
|
Question |
|
I’m not wheezing right now . . . But I did wheeze a little bit a few days ago at my cousin’s house. I had to use my inhaler. (Clarified to how my wheezing is.)
|
|
|
What do you use for your asthma? inhaler?
|
Question |
|
It’s just a regular Proventil inhaler.
|
|
|
how many times do you use the inhaler?
|
Question |
|
I don’t use it every day. Maybe two or three times a week. Although I guess lately, once I have to use it once, sometimes I need it again that day.
|
|
|
have you been been hospitalized for asthma?
|
Question |
|
I went a bunch of times when I was little, for asthma attacks.
|
|
|
What else have you used for the asthma? (No matching questions found.)
|
Question |
|
What else have you used for the asthma?what causes your asthma?
|
Question |
|
When I used to have asthma attacks all the time, all different things could cause them. . . sometimes I couldn’t tell what was doing it. My breathing problems haven’t turned into a full attack in years, though.
|
|
|
What happens when you are around cats?
|
Question |
|
Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up.
|
|
|
Do you have latex allergies?
|
Question |
|
Nope.
|
|
|
Do you have food allergies?
|
Question |
|
Nope, no food allergies that I know of.
|
|
|
are you allergic to dust?
|
Question |
|
Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust.
|
|
|
Are you allergic to pollen ?
|
Question |
|
Not that I’ve noticed.
|
|
|
are you allergic to mold?
|
Question |
|
None that I know of.
|
|
|
Are you allergic to penicillin ?
|
Question |
|
Yes.
|
|
|
what type of reaction do you have to penicillin?
|
Question |
|
I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that.
|
|
|
Do you have other allergies?
|
Question |
|
Well, besides cats, I’m allergic to penicillin.
|
|
|
any other seasonal asthma triggers?
|
Question |
|
No, not really.
|
|
|
Any past asthma medications? (No matching questions found.)
|
Question |
|
Any past asthma medications?When were you diagnosed of Diabetes? (Clarified to How old were you when you were diagnosed with diabetes?.)
|
Question |
|
I was diagnosed when I was 24. (Clarified to when I was diagnosed with diabetes.)
|
|
|
What type of diabetes do you have?
|
Question |
|
It’s type 2.
|
|
|
do you take any medication for diabetes?
|
Question |
|
I don’t take anything for my diabetes anymore.
|
|
|
why did you stop? (Clarified to Why did you stop taking diabetes medication?.)
|
Question |
|
I just got sick of dealing with it! (Clarified to why I stopped taking my diabetes medication.)
|
|
|
Were you unable to afford the medication? (No matching questions found.)
|
Question |
|
WIts not advisable to stop medication without consulting your doctor, it can have negative effects?
|
Educate |
|
Sure, I think I understand what you mean.
|
|
|
What diabetes medication were you taking?
|
Question |
|
It was Metformin.
|
|
|
would you afford the metformin? (Clarified to Did you have issues affording the metformin?.)
|
Question |
|
I haven’t had trouble affording medication . . . Cost wasn’t really the issue with the metformin. I just got really sick of having to take it, and I hated the side effects. [AUDIO COMING SOON] (Clarified to if I had problems affording the metformin.)
|
|
|
had you any other challenges accessing metformin? (No matching questions found.)
|
Question |
|
what dosage of metformin were you taking?
|
Question |
|
Honestly, I don’t remember what the dose was when I was taking it.
|
|
|
How many times were you taking metformin?
|
Question |
|
I think it was one pill, twice a day.
|
|
|
when did you stop taking metformin?
|
Question |
|
About three years ago, honestly.
|
|
|
when did you start taking metformin?
|
Question |
|
When I was 24, right after I was first diagnosed.
|
|
|
did you tell your doctor that you stopped taking metformin?
|
Question |
|
No, I just stopped taking it because I was sick of dealing with taking it everyday and feeling gassy all the time.
|
|
|
Its good to have a plan with the doctor before stopping medication
|
Educate |
|
OK, I understand.
|
|
|
How old are you now?
|
Question |
|
||
ORDER A PLAGIARISM-FREE PAPER HERE |
||
|
I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets.
|
|
|
How is your appetite?
|
Question |
|
My appetite’s been huge lately. . . I feel like I’m hungry all the time.
|
|
|
Do you notice any change in weight?
|
Question |
|
Yeah, I’ve lost some weight recently.
|
|
|
Are you trying to lose weight?
|
Question |
|
No, I’m not trying to lose weight, but I did lose a little recently without meaning to. About ten pounds in the last month. [AUDIO COMING SOON]
|
|
|
Do you have hypertension?
|
Question |
|
No, I’ve never been diagnosed with blood pressure problems.
|
|
|
Do you check your blood pressure regularly?
|
Question |
|
I almost never check it. I mean, maybe twice a year I might? It’s not something I think about.
|
|
|
do you know your blood pressure range?
|
Question |
|
It’s . . . oh, I don’t remember exactly because I never write it down. Let me try to remember . . . I feel like it’s usually around 140. And the bottom number is 80 or 90. I do know the last time in the ER it was something like 141/92. They said it was on the high side. [AUDIO COMING SOON]
|
|
|
The standard rate reading 12 120/80. Sure that on the higher side, you need to monitor it as well.
|
Educate |
|
Alright, thanks for letting me know.
|
|
|
When did you have your last immunization?
|
Question |
|
I think the last time I got shots was when I enrolled in college the first time. Oh, and I got a tetanus booster about a year ago.
|
|
|
Have you received the influenza vaccine ?
|
Question |
|
No.
|
|
|
Did you complete your childhood immunizations? (Clarified to Are you up to date on immunizations?.)
|
Question |
|
I’m pretty sure they are all taken care of. (Clarified to if I am up to date on shots.)
|
|
|
Do you use over the counter medications?
|
Question |
|
I take Tylenol for a headache sometimes, or Advil for cramps, but not often.
|
|
|
What dosage of tylenol?
|
Question |
|
I just take one or two of the 500 mg acetaminophen. I usually get the headaches at night from reading — squinting I guess — and so I take one or two and go to bed. [AUDIO COMING SOON]
|
|
|
what dosage of advil do you take?
|
Question |
|
I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON]
|
|
|
How long have you been taking tramadol ?
|
Question |
|
I started needing them two days ago.
|
|
|
when did you take the last tramadol?
|
Question |
|
This morning I took two pain pills right before I came here, at around 8:30.
|
|
|
Do you take vitamin supplements?
|
Question |
|
I don’t take vitamins or supplements.
|
|
|
Do you take herbal drugs? (Clarified to Do you take any herb supplements?.)
|
Question |
|
No, I don’t take anything herbal. (Clarified to if I take herbal supplements.)
|
|
|
What is your highest level of educations?
|
Question |
|
Well, I’m finishing up my Bachelor’s degree right now.
|
|
|
How is college life? (Clarified to Is college a stressful time?.)
|
Question |
|
I don’t get stressed out much, but sometimes having such a hectic schedule can be a lot. Right now, though, I’m mostly worried about my foot. (Clarified to if college is stressful.)
|
|
|
Do you have financial problems accessing education ?
|
Question |
|
I’m doing okay–I earn a pretty good wage at my job, but I do have to be careful with money since I’m still paying tuition. Right now I’m lucky to be able to save some money by living at my Mom’s house instead of paying rent.
|
|
|
Any financial problems accessing healthcare?
|
Question |
|
I’m doing okay–I earn a pretty good wage at my job, but I do have to be careful with money since I’m still paying tuition. Right now I’m lucky to be able to save some money by living at my Mom’s house instead of paying rent.
|
|
|
Great, its good to continue with education nd also save money when you can.
|
Educate |
|
OK, I understand.
|
|
|
What is your major at the college?
|
Question |
|
I’m going to get my bachelor’s in accounting.
|
|
|
Do you have a belief system?
|
Question |
|
Yeah. We go to First Baptist, and we do a lot with our church community. Even before a service, it’s pretty social; we go early so we can meet and talk with everybody. And I go to the Wednesday night Bible study group. There’s other events, too, pot-lucks, all of that. Oh, and once a month the church organizes like a volunteer event, so I try to do that. We spend a lot of time with our church family.
|
|
|
sounds like you have great social and religious conections
|
Empathize |
|
I appreciate you telling me that.
|
|
|
Do you smoke tobacco?
|
Question |
|
No. I think it’s gross.
|
|
|
Do you hang around people who smoke?
|
Question |
|
Yeah, a couple of my friends smoke when we go out. I don’t like being around smokers, though.
|
|
|
Its good to avoid smoke, it is not good for asthma
|
Educate |
|
That makes sense.
|
|
|
Do you smoke marijuana?
|
Question |
|
Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.
|
|
|
how old were you then? (No matching questions found.)
|
Question |
|
why did you stop smoking?
|
Question |
|
It just wasn’t that fun anymore, plus it started to bother my asthma.
|
|
|
Do you vape?
|
Question |
|
I’ve never vaped or smoked an e-cigarette. [AUDIO COMING SOON]
|
|
|
do you smoke the pot?
|
Question |
|
Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.
|
|
|
At what age did you smoke?
|
Question |
|
I started when I was about fifteen, and I stopped when I was twenty or twenty-one.
|
|
|
Do you drink alcohol?
|
Question |
|
I do sometimes, yeah, when I go out with my friends.
|
|
|
How much alcohol do you take in a sitting? (Clarified to How much alcohol do you usually drink in one sitting?.)
|
Question |
|
I never have more than two or three. If I go over that, I feel like hell the next day, so I stick to just a few. (Clarified to how much alcohol I drink in one sitting.)
|
|
|
How often do you drink?
|
Question |
|
No more than once or twice a week, sometimes less.
|
|
|
Its good not to take a lot of alcohol and also to stop taking recreational drugs, they are addictive. (No matching questions found.)
|
Question |
|
Its good not to take a lot of alcohol and also to stop taking recreational drugs, they are addictive.
|
Educate |
|
Sure, I think I understand what you mean.
|
|
|
Do you take coffee?
|
Question |
|
Never. I don’t like it. Too bitter for my taste.
|
|
|
Do you take carbonated sodas? (No matching questions found.)
|
Question |
|
Do you take sodas? (No matching questions found.)
|
Question |
|
Do you smoke the pot?
|
Question |
|
Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.
|
|
|
Am happy that you stooped smoking pot, its not good for your health, especially asthma. (No matching questions found.)
|
Question |
|
Am happy that you stooped smoking pot, its not good for your health, especially asthma.
|
Educate |
|
Alright, thanks for letting me know.
|
|
|
Who do you love with? (Clarified to Who do you live with?.)
|
Question |
|
Right now I live back at home with my mom and my sister. (Clarified to who I live with.)
|
|
|
Have you been abused?
|
Question |
|
No, no way. I’ve never been hurt or anything in the way that you’re talking about.
|
|
|
||
WE GUARANTEE A DCE SCORE OF ABOVE 95% AND HANDLE THE SOAP NOTE |
||
|
Sorry for the discomforts
|
Empathize |
|
Thanks for understanding.
|
|
|
Do you have a boyfriend?
|
Question |
|
Um, not right now.
|
|
|
Have you had a boyfriend in the past?
|
Question |
|
Um, not right now.
|
|
|
How many boyfriends you had? (Clarified to How many boyfriends have you had?.)
|
Question |
|
Oh, gosh…I guess four or five. (Clarified to how many boyfriends I have had.)
|
|
|
Have you tested for HIV/AIDS?
|
Question |
|
No. I don’t think I need one. I don’t know anybody with HIV or AIDS.
|
|
|
Have you tested for STDs? (Clarified to Have you been tested for STDs?.)
|
Question |
|
Yeah, I’m sure they did those tests when I went for a pap smear before. (Clarified to if I have ever been tested for STDs.)
|
|
|
Have you been tested for STDs with your boyfriend? (Clarified to Has your friend been checked for sexually transmitted infections?.)
|
Question |
|
When we were together, he told me he didn’t have any STDs, and I believed him. I don’t know if he was ever tested. (Clarified to if my sexual partner has been tested for STIs.)
|
|
|
It is good to be tested for STDs to be sure
|
Educate |
|
Sure, I think I understand what you mean.
|
|
|
When were you tested for stds?
|
Question |
|
I guess probably the last time I went for a pap smear…that was, um, maybe four years ago now.
|
|
|
Do you have any symptoms for STDs?
|
Question |
|
No. I’ve never had any symptoms like that.
|
|
|
Any vaginal discharge?
|
Question |
|
Um, I have hardly any discharge, and it’s, like, clear.
|
|
|
Have you had any muscle pain?
|
Question |
|
No.
|
|
|
Any joint pain?
|
Question |
|
No.
|
|
|
Joint swelling? (Clarified to Do you have any joint pain or swelling?.)
|
Question |
|
Not really. (Clarified to if I have any joint pain or swelling.)
|
|
|
what about back pain?
|
Question |
|
My back’s fine.
|
|
|
How are your eyes?
|
Question |
|
I’ve actually been noticing problems lately. When I’m reading or studying I’ll notice that things start to get kind of blurry.
|
|
|
Do you wear eye glasses?
|
Question |
|
I don’t wear glasses–or contacts.
|
|
|
Do you have any problem with moth or jaw? (Clarified to Do you have mouth or jaw problems?.)
|
Question |
|
No, neither. (Clarified to if I have mouth or jaw problems.)
|
|
|
Have you had any dental problems?
|
Question |
|
Nope, no problems.
|
|
|
Any change in sense of taste?
|
Question |
|
No, I think my sense of taste is fine.
|
|
|
Do have a painful mouth?
|
Question |
|
No.
|
|
|
Any difficulties swallowing?
|
Question |
|
Nope.
|
|
|
Any sore throat?
|
Question |
|
No, it’s fine.
|
|
|
Any swollen glands?
|
Question |
|
No, not that I noticed.
|
|
|
Have you had a breast exam?
|
Question |
|
I haven’t had a mammogram. I’ve just had the exam where the doctor felt around for lumps.
|
|
|
any pain in the breasts
|
Question |
|
No. Maybe some soreness before my period, but that seems pretty typical.
|
|
|
any discharge from nipples?
|
Question |
|
Uh, no, definitely not.
|
|
|
have you nosebleed?
|
Question |
|
No.
|
|
|
Any chest pains?
|
Question |
|
No, my chest feels tight when I have breathing problems, but it doesn’t hurt.
|
|
|
Any irregular heartbeat? (Clarified to Have you ever had an irregular heartbeat?.)
|
Question |
|
I think my heart’s fine. I don’t really notice how it beats. (Clarified to if I have had an irregular heartbeat.)
|
|
|
do you have problems with your bowel problems? (Clarified to Do you have difficulty moving your bowels?.)
|
Question |
|
No. No problems like that. (Clarified to if I have trouble moving my bowels.)
|
|
|
Have you noticed any changes with your skin?
|
Question |
|
Well…I guess I was noticing the other day that the skin around my neck is looking weird. Like the skin is getting darker. And my skin’s breaking out, but that’s how it is.
|
|
|
What is your general heath condition?
|
Question |
|
Generally? My foot has just been hurting from a scrape I got. [AUDIO COMING SOON]
|
|
|
Are you tired or fatigued?
|
Question |
|
Most days I feel pretty exhausted by the end of the day…I’m tired now, too, but I think that’s just because I slept terribly.
|
|
|
How is your sleep pattern?
|
Question |
|
I try to be in bed by eleven or midnight, and I get up at seven or eight.
|
|
|
Do eyes itch?
|
Question |
|
No. That only happens around cats or dust.
|
|
|
Any hearing problem?
|
Question |
|
No.
|
|
|
Any ear discharge?
|
Question |
|
No.
|
|
|
does your mother have any health problem?
|
Question |
|
Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
|
|
|
Does your father have medical problems?
|
Question |
|
Well, he passed away. But he had a couple things . . . Type 2 diabetes, like me, and high cholesterol and blood pressure.
|
|
|
Am sorry to hear that.
|
Empathize |
|
I appreciate you telling me that.
|
|
|
When did your farther pass away? (Clarified to When did your father pass away?.)
|
Question |
|
It was last year… I guess a little over a year ago. (Clarified to when my dad died.)
|
|
|
How old was your father when he passed away?
|
Question |
|
Last year when Dad passed, he was only 58.
|
|
|
How did you cope with your fathers death?
|
Question |
|
Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kinda depressed. So I guess at first I just focused on getting things done–groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kinda helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out, and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months.
|
|
|
You are lucky you have a great support system that helped you cope easily.
|
Empathize |
|
Thanks for saying that.
|
|
|
What was the cause of your fathers death?
|
Question |
|
He died in a car accident.
|
|
|
Am sorry to hear that
|
Empathize |
|
I appreciate you saying that.
|
|
|
||
ORDER A PLAGIARISM-FREE PAPER HERE |
||
|
No, I’m fine right now.
|
|
|
Measured wound: 2 cm x 1.5 cm, 2.5 mm deep
|
Exam Action |
|
Swabbed wound and sent to lab for C & S
|
Exam Action |
|
Cleansed and irrigated wound with normal saline and applied dry sterile dressing.
|
Exam Action |