tina jones HEENT shadow health assessment transcript

Transcript

Started: May 17, 2020 | Total Time:96 min

Hello. My name is xxx. I will be interviewing you today and then conduct a physical exam.

Greet
05/29/20 6:31 PM EDT

Hey.

May i know your name please?

Question
05/29/20 6:31 PM EDT

Tina Jones.

What brings you the the Clinic today Tina?

Question
05/29/20 6:31 PM EDT

My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.

Am sorry to hear that

Empathize
05/29/20 6:32 PM EDT

I appreciate you telling me that.

How long have you had these symptoms?

Question
05/29/20 6:32 PM EDT

My itchy eyes, runny nose, and sore throat all started a week ago. [AUDIO COMING SOON]

Have you ever had these symptoms before?

Question
05/29/20 6:33 PM EDT

No.

How severe is your sore throat?

Question
05/29/20 6:36 PM EDT

It’s not… terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won’t go away.

Is the sore throat constant

Question
05/29/20 6:36 PM EDT

Yeah, it’s sore pretty much all the time.

can you describe the pain?

Question
05/29/20 6:38 PM EDT

It’s really sore, and it itches a lot, like in the back.

how would you rate te pain on a scale of 0 to 10 ?

Question
05/29/20 6:38 PM EDT

It’s like a 4 out of 10, maybe.

Does the pain radiate?

Question
05/29/20 6:38 PM EDT

No, it’s just in my throat.

What do you think is casing the sore throat?

Question
05/29/20 6:39 PM EDT

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.

Does anything make the throat feel better?

Question
05/29/20 6:40 PM EDT

All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.

Does anything make the pain worse?

Question
05/29/20 6:41 PM EDT

It’s a little worse in the morning, but that’s really the only pattern I’ve noticed.

Do you have any other symptoms associated with the sore throat? (No matching questions found.)

Question
05/29/20 6:43 PM EDT

do you have any nasal discharge?

Question
05/29/20 6:43 PM EDT

Yes, it won’t stop running!

Do you take any over the counter medications?

Question
05/29/20 6:50 PM EDT

I’ve been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often.

How often do you get headaches?

Question
05/29/20 6:51 PM EDT

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 would you rate these headaches?

Question
05/29/20 6:51 PM EDT

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

What helps your headache?

Question
05/29/20 6:51 PM EDT

I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON]

Does anything make your headache worse?

Question
05/29/20 6:52 PM EDT

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.

How long have you had these headaches?

Question
05/29/20 6:52 PM EDT

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

Do you take any herbal supplements?

Question
05/29/20 6:53 PM EDT

No, I don’t take anything herbal.

Do you take any prescription medications?

Question
05/29/20 6:53 PM EDT

Do you take vitamins?

Question
05/29/20 7:21 PM EDT

No, I don’t take any vitamins.

Are your immunizations up to date?

Question
05/29/20 7:22 PM EDT

I’m pretty sure I am, yeah.

What side effects did you have with metformin?

Question
05/29/20 7:23 PM EDT

I felt sick and gassy all the time. It was really uncomfortable.

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

Educate
05/29/20 7:25 PM EDT

Alright, thanks for letting me know.

Are you allergic to medications?

Question
05/29/20 7:28 PM EDT

Yeah, I’m allergic to penicillin.

Do you have seasonal allergies?

Question
05/29/20 7:28 PM EDT

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.

Do you have food allergies? Are you allergic to latex? (Clarified to Do you have food allergies?.)

Question
05/29/20 7:29 PM EDT

Nope, no food allergies that I know of. (Clarified to if I have food allergies.)

Do you smoke cigarettes?

Question
05/29/20 7:32 PM EDT

No, I’ve never smoked a cigarette in my life.

Do you take alcohol? (No matching questions found.)

Question
05/29/20 7:32 PM EDT

Do you drink alcohol?

Question
05/29/20 7:33 PM EDT

I do sometimes, yeah, when I go out with my friends.

How many drinks do you take when you go out? (Clarified to How many drinks do you have when you go out at night?.)

Question
05/29/20 7:33 PM EDT

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.)

Thats moderate drinking which is ok.

Educate
05/29/20 7:34 PM EDT

Thanks for telling me.

What type of alcohol do you take?

Question
05/29/20 7:34 PM EDT

I usually get rum and diet Coke. I don’t know why that matters.

Different drinks have different alcohol levels, thats why i asked.

Educate
05/29/20 7:35 PM EDT

OK, I understand.

How is your family medical history?

Question
05/29/20 7:35 PM EDT

My mom has some issues, and I think some of my grandparents did, too.

What health issues does your mother have?

Question
05/29/20 7:35 PM EDT

Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

What medical issues does your father have? (Clarified to Tell me about your dad’s health?.)

Question
05/29/20 7:36 PM EDT

He passed last year. (Clarified to what health issues my dad has.)

Am sorry to hear that

Empathize
05/29/20 7:36 PM EDT

Thanks for understanding.

did your father have any medical conditions?

Question
05/29/20 7:37 PM EDT

He had high blood pressure and cholesterol, and diabetes too…the same kind as me.

What health issues does your maternal grandmother have?

Question
05/29/20 7:37 PM EDT

Nana had high blood pressure and cholesterol, I think.

What issues does you maternal grandfather have?

Question
05/29/20 7:38 PM EDT

Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.

What health issues does you paternal grand mother have?

Question
05/29/20 7:38 PM EDT

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.

What health issues does your paternal grandfather have?

Question
05/29/20 7:39 PM EDT

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.

how did you cope with your fathers death?

Question
05/29/20 7:39 PM EDT

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.

Seems you have a strong support system which is great.

Empathize
05/29/20 7:40 PM EDT

Thanks.

What health conditions does your sister have?

Question
05/29/20 7:41 PM EDT

She’s pretty healthy. She has asthma too, but she almost never has attacks.

what health conditions does your brother have?

Question
05/29/20 7:41 PM EDT

None that I know of. He’s got some extra weight on him, I guess.

Anyone one with an obesity problem in your family?

Question
05/29/20 7:45 PM EDT

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.

Any one with alcoholism problem in the family?

Question
05/29/20 7:46 PM EDT

One person in the family, my dad’s brother, has an alcohol problem, but we never see him.

What work do you do?

Question
05/29/20 7:47 PM EDT

I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up.

Am happy to hear that your job is fine and you are doing well

Empathize
05/29/20 7:47 PM EDT

Thanks for understanding.

What is your highest level of education?

Question
05/29/20 7:48 PM EDT

Well, I’m finishing up my Bachelor’s degree right now.

What is your Major?

Question
05/29/20 7:48 PM EDT

I’m going to get my bachelor’s in accounting.

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.

Am sure when you get less busy, you will travel more

Empathize
05/29/20 7:52 PM EDT

I appreciate you saying that.

Have you been wheezing?

Question
05/29/20 7:52 PM EDT

No, I haven’t been wheezing this week.

Please let me examine you now. (No matching questions found.)

Question
05/29/20 7:53 PM EDT

Please let me examine you now.

Educate
05/29/20 7:53 PM EDT

Sure, I think I understand what you mean.

Inspected general face

Exam Action
05/29/20 7:57 PM EDT

Inspected forehead and scalp