Tina Jones HEENT Shadow Health Assessment Transcript
Transcript
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Hello. My name is xxx. I will be interviewing you today and then conduct a physical exam.
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Greet |
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Hey.
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May i know your name please?
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Tina Jones.
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What brings you the the Clinic today Tina?
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My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
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Am sorry to hear that
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Empathize |
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I appreciate you telling me that.
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How long have you had these symptoms?
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My itchy eyes, runny nose, and sore throat all started a week ago. [AUDIO COMING SOON]
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Have you ever had these symptoms before?
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No.
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How severe is your sore throat?
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It’s not… terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won’t go away.
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Is the sore throat constant
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Yeah, it’s sore pretty much all the time.
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can you describe the pain?
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It’s really sore, and it itches a lot, like in the back.
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how would you rate te pain on a scale of 0 to 10 ?
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It’s like a 4 out of 10, maybe.
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Does the pain radiate?
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No, it’s just in my throat.
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What do you think is casing the sore throat?
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At first I thought I was getting sick, or a cold or something, but now it doesn’t seem like that. My throat hasn’t gotten worse, but it’s not going away either.
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Does anything make the throat feel better?
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All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
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Does anything make the pain worse?
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It’s a little worse in the morning, but that’s really the only pattern I’ve noticed.
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Do you have any other symptoms associated with the sore throat? (No matching questions found.)
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do you have any nasal discharge?
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Yes, it won’t stop running!
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Do you take any over the counter medications?
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I’ve been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often.
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How often do you get headaches?
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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.
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How would you rate these headaches?
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Not too bad. . . I’d say about 3. Or a 4 if I really push it.
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What helps your headache?
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I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON]
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Does anything make your headache worse?
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Usually they get worse if I don’t stop studying. I try to take a break when they start most of the time, but if I have a test or something coming up, I just have to try and ignore it.
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How long have you had these headaches?
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I’m not sure — Maybe over the last year or so.
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Do you take any herbal supplements?
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No, I don’t take anything herbal.
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Do you take any prescription medications?
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WE GUARANTEE A DCE SCORE OF ABOVE 95% AND HANDLE THE SOAP NOTE
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Do you take vitamins?
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No, I don’t take any vitamins.
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Are your immunizations up to date?
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I’m pretty sure I am, yeah.
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What side effects did you have with metformin?
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I felt sick and gassy all the time. It was really uncomfortable.
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When you get side effects that you cannot tolerate, you should speak to your doctor for alternatives and also confirm if they react with other medicatiobs
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Alright, thanks for letting me know.
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Are you allergic to medications?
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Yeah, I’m allergic to penicillin.
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Do you have seasonal allergies?
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Well, no. I mean, I never had allergies to pollen or anything outdoors like that. . . But my nose is acting just like my sister’s right now, and she’s always had hay fever. I’m starting to think that this is allergies.
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Do you have food allergies? Are you allergic to latex? (Clarified to Do you have food allergies?.)
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Nope, no food allergies that I know of. (Clarified to if I have food allergies.)
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Do you smoke cigarettes?
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No, I’ve never smoked a cigarette in my life.
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Do you take alcohol? (No matching questions found.)
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Do you drink alcohol?
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I do sometimes, yeah, when I go out with my friends.
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How many drinks do you take when you go out? (Clarified to How many drinks do you have when you go out at night?.)
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Like, two or three drinks. If I have more than two or three drinks, I feel like hell the next day, so I stop at three. (Clarified to how many alcoholic drinks I have when I go out.)
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Thats moderate drinking which is ok.
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Educate |
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Thanks for telling me.
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What type of alcohol do you take?
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I usually get rum and diet Coke. I don’t know why that matters.
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Different drinks have different alcohol levels, thats why i asked.
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OK, I understand.
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How is your family medical history?
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My mom has some issues, and I think some of my grandparents did, too.
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What health issues does your mother have?
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Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
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What medical issues does your father have? (Clarified to Tell me about your dad’s health?.)
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He passed last year. (Clarified to what health issues my dad has.)
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Am sorry to hear that
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Empathize |
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Thanks for understanding.
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did your father have any medical conditions?
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He had high blood pressure and cholesterol, and diabetes too…the same kind as me.
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What health issues does your maternal grandmother have?
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Nana had high blood pressure and cholesterol, I think.
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What issues does you maternal grandfather have?
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Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
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What health issues does you paternal grand mother have?
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Granny’s doing good. She’s still living on her own. She’s slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy.
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What health issues does your paternal grandfather have?
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Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and…I’m pretty sure he had diabetes.
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how did you cope with your fathers death?
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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.
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Seems you have a strong support system which is great.
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Empathize |
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Thanks.
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What health conditions does your sister have?
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She’s pretty healthy. She has asthma too, but she almost never has attacks.
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what health conditions does your brother have?
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None that I know of. He’s got some extra weight on him, I guess.
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Anyone one with an obesity problem in your family?
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No, I don’t think so. My brother and my dad are kind of big, but I wouldn’t say they were obese or anything.
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Any one with alcoholism problem in the family?
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One person in the family, my dad’s brother, has an alcohol problem, but we never see him.
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What work do you do?
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I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up.
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Am happy to hear that your job is fine and you are doing well
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Empathize |
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Thanks for understanding.
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What is your highest level of education?
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Well, I’m finishing up my Bachelor’s degree right now.
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What is your Major?
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I’m going to get my bachelor’s in accounting.
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I really haven’t travelled that much…I’ve always wanted to go to France but I’ve never even been out of the country. I’m always busy with work or school anyway though. We used to go on some family vacations when I was younger, but they were usually just to see some family in other states.
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Am sure when you get less busy, you will travel more
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Empathize |
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I appreciate you saying that.
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Have you been wheezing?
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No, I haven’t been wheezing this week.
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Please let me examine you now. (No matching questions found.)
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Please let me examine you now.
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Educate |
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Sure, I think I understand what you mean.
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Inspected general face
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Inspected forehead and scalp
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Inspected nose and mouth
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Inspected left side of face
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Inspected back of head
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Inspected right side of face
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Inspected general face
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Inspected right side of face
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Inspected general face
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Inspected nose and mouth
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Inspected forehead and scalp
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Inspected nose and mouth
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Inspected right orbital area and sclera
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Inspected lower conjunctiva
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Inspected upper conjunctiva
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Inspected upper conjunctiva
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Inspected left orbital area and sclera
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Performed otoscopic examination of right naris
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Performed otoscopic examination of left naris
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Performed otoscopic examination of right ear
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Performed otoscopic examination of left ear
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Inspected mouth
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Inspected mouth: pushed tongue left with tongue blade
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Inspect mouth: pushed tongue right with tongue blade
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Inspect mouth: lifted tongue with tongue blade
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Inspected mouth: depressed tongue with tongue blade
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Inspected front of neck
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Inspected left side of neck
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Inspected back of neck
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Inspected right side of neck
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Inspected back of neck
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Inspected right side of neck
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Inspected front of neck
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Inspected right side of neck
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Inspected front of neck
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Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported
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Palpated maxillary sinuses: No tenderness reported
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Palpated frontal sinuses: No tenderness reported
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Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+
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Palpated right carotid artery: No thrill, 2+
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Palpated left carotid artery: No thrill, 2+
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Palpated jaw: Full range of motion, no popping or clicking
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Palpated axillary lymph nodes: Not palpable
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Palpated supraclavicular lymph nodes: Not palpable
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Palpated lymph nodes of head and neck: Not palpable
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Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported
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Auscultated breath sounds in anterior right lower lobe
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Auscultated breath sounds in anterior right middle lobe
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Auscultated breath sounds in anterior right upper lobe
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Auscultated breath sounds in anterior left upper lobe
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Auscultated breath sounds in anterior left mid-chest (upper lobe)
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Auscultated breath sounds in anterior left lower lobe
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Auscultated breath sounds in posterior left upper lobe
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Auscultated breath sounds in posterior left mid-back (lower lobe)
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Auscultated breath sounds in posterior left lower lobe
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Auscultated breath sounds in posterior left lower lobe on side
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Auscultated breath sounds in posterior left lower lobe near spine
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Auscultated breath sounds in posterior right lower lobe near spine
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Auscultated breath sounds in posterior right lower lobe on side
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Auscultated breath sounds in posterior right lower lobe
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Auscultated breath sounds in posterior right mid-back (lower lobe)
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Auscultated breath sounds in posterior right upper lobe
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Auscultated right temporal pulse
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Auscultated left temporal pulse
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Auscultated right carotid pulse
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Auscultated left carotid pulse
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Tested left pupillary reaction with penlight
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Tested right pupillary reaction with penlight
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Follow my finger with just your eyes
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Ok.
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Tested EOM to the upper right
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Tested EOM to the lower right
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Tested EOM to the lower center
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Tested convergence to the center
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Tested EOM to the upper center
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Tested EOM to the upper left
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Tested EOM to the lower left
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Tell me when you can no loner see
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Ok, I will.
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Tested peripheral vision
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Now.
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Examined fundus of right eye with ophthalmoscope
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Examined fundus of left eye with ophthalmoscope
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F P
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Is the volume the same in both ears or louder in one ear
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Ok.
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Same in both ears.
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Performed Weber test with tuning fork
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Tell me when you no longer hear the ringing
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Ok, I will.
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Now.
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F.
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F.
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Eight
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Eight.
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W.
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W.
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Performed whisper test in right ear
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Four
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Four.
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R.
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R.
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Nine.
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Nine.
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Performed whisper test in left ear
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Tested gag reflex with tongue blade
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