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Hello, my name is. I will be conducting an interview and later perform a physical exam. |
Greet 07/22/20 5:37 PM EDT |
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Hey. |
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What is your name? |
Question 07/22/20 5:37 PM EDT |
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Tina Jones. |
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Your date of birth? |
Question 07/22/20 5:37 PM EDT |
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February 17th. |
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How old are you?
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Question 07/22/20 5:43 PM EDT |
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I’m 28. |
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What brought you to the clinic today? |
Question 07/22/20 5:43 PM EDT |
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I came in because I’m required to have a recent physical exam for the health insurance at my new job. |
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Do you have any current health problem? |
Question 07/22/20 5:44 PM EDT |
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I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I’m taking good care of my health these days. |
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What is your new job? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation |
Question 07/22/20 5:44 PM EDT |
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I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks–I’m really excited! |
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That is great. |
Empathize 07/22/20 5:45 PM EDT |
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Thanks. |
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When was your last physical exam? |
Question 07/22/20 5:45 PM EDT |
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Let’s see . . . I had two doctor’s appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear. |
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What did your gynecologist say? |
Question 07/22/20 5:45 PM EDT |
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She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things. |
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How often do you take birth control? |
Question 07/22/20 5:48 PM EDT |
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I take it every morning, with breakfast. |
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What is the name of the birth control pill you took? |
Question 07/22/20 5:49 PM EDT |
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They’re called Yaz. |
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Has your menstrual cycle improved since taking Yaz? |
Question 07/22/20 5:50 PM EDT |
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Now that I’m on the pill I’m getting my period every month. |
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That is great. I am glad you are having your period every month. |
Empathize 07/22/20 5:50 PM EDT |
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Thanks. |
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How long have you had asthma. |
Question 07/22/20 5:51 PM EDT |
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I’ve had asthma a long time. . . since I was really little. |
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What age were you diagnosed with asthma? |
Question 07/22/20 5:51 PM EDT |
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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. |
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I am sorry about the experience. |
Empathize 07/22/20 5:52 PM EDT |
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Thanks. |
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How do you manage your asthma? |
Question 07/22/20 5:52 PM EDT |
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I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. |
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What are your triggers for asthma? |
Question 07/22/20 5:53 PM EDT |
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Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t had a full asthma attack in years, though. |
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It is important to stay away from triggers. |
Educate 07/22/20 5:54 PM EDT |
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Thanks for telling me. |
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What happens when you are around dust? |
Question 07/22/20 5:54 PM EDT |
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I used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn’t happened since I got my daily inhaler. |
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What inhaler do you use? |
Question 07/22/20 5:59 PM EDT |
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The daily inhaler is Flovent, and the rescue inhaler is Proventil. |
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How often do you use flovent? |
Question 07/22/20 6:00 PM EDT |
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Twice a day. |
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When did you most recently use the flovent inhaler? |
Question 07/22/20 6:01 PM EDT |
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I use my Flovent inhaler two times a day. |
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When did you last use your inhaler? |
Question 07/22/20 6:03 PM EDT |
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I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol. . . I’ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too. |
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How much Albuterol do you use? |
Question 07 |
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I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church. |
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What is your relationship like with your family? |
Question 07/22/20 7:39 PM EDT |
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Things are pretty good between all of us–we’re a tight knit family. I think we’re pretty special, the way we all get along. |
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That is great. |
Empathize 07/22/20 7:39 PM EDT |
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Thanks. |
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Are you involved in church? |
Question 07/22/20 7:39 PM EDT |
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Yeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too. |
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Are you feeling stressed? |
Question 07/22/20 7:40 PM EDT |
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I’m actually feeling really good lately. . . not stressed at all. |
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How do you cope with stress? |
Question 07/22/20 7:40 PM EDT |
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I’ve realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. So I’ve been trying to address problems as they come when I can, and that helps. That, plus the stuff I’ve always done–going to church, especially–is all working well for me. |
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That is good to hear. |
Empathize 07/22/20 7:40 PM EDT |
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Thanks. |
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Are you feeling depressed? |
Question 07/22/20 7:41 PM EDT |
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No, I’m actually feeling really good these days. |
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How do you feel about your life? |
Question 07/22/20 7:41 PM EDT |
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Well, I’m starting my new job in two weeks, and I’m really excited about that. I’m going to be an Accounting Clerk at this really nice accounting firm. I’m hoping I’ll learn a lot in that position, and within a couple years, I’ll get promoted and be given new responsibilities. I just always want to be learning new things and getting better at my job. |
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Are you feeling anxious? |
Question 07/22/20 7:41 PM EDT |
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I guess I had anxiety back when I was having those sleep problems. . . I’ve been feeling much better lately, though. |
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Do you have sleeping problems? |
Question 07/22/20 7:42 PM EDT |
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I’m sleeping a lot better now, which is a relief. |
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Good to hear. |
Empathize 07/22/20 7:42 PM EDT |
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Thanks. |
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How many hours are you sleeping a night? |
Question 07/22/20 7:42 PM EDT |
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I’m usually asleep by 11:30, and I wake up at 8, so. . . about 8 or 9 hours a night. |
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That is great. |
Empathize 07/22/20 7:42 PM EDT |
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Thanks. |
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Have you ever smoked tobacco? |
Question 07/22/20 7:43 PM EDT |
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No. I think it’s gross. |
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Have you ever used cocaine? |
Question 07/22/20 7:43 PM EDT |
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No way, I have no interest in that. That stuff can mess you up. |
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Have you ever used heroin? |
Question 07/22/20 7:49 PM EDT |
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Uh, no. |
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Have you ever used illegal drugs? |
Question 07/23/20 3:17 PM EDT |
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Well, I used to smoke pot. . . but I don’t do that anymore. |
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What was the last time you smoked pot? |
Question 07/23/20 3:17 PM EDT |
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I haven’t smoked pot since I was twenty or twenty-one. |
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Do you have any family history of mental illness? |
Question 07/23/20 3:18 PM EDT |
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No. They’re crazy, but nobody’s diagnosed with anything. |
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Have you had suicidal thoughts? |
Question 07/23/20 3:19 PM EDT |
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No, I’ve never done that. |
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Any new family medical history report? |
Question 07/23/20 3:20 PM EDT |
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My mom has some issues, and I think some of my grandparents did, too. |
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How old is your mom? |
Question 07/23/20 3:21 PM EDT |
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Mom is 50. |
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What medical problems does your mum have? |
Question 07/23/20 3:21 PM EDT |
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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 problems did your father have? |
Question 07/23/20 3:22 PM EDT |
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He had high blood pressure and cholesterol, and diabetes too…the same kind as me. |
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How old is your brother? |
Question 07/23/20 3:24 PM EDT |
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He’s almost 27. |
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Does he have any medical issue? (Clarified to Does your younger sister have health problems?.) |
Question 07/23/20 3:25 PM EDT |
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She’s pretty healthy. She has asthma too, but she almost never has attacks. (Clarified to if my younger sister has health problems.) |
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Does your bother have health issues? (Clarified to Does your brother have medical problems?.) |
Question 07/23/20 3:25 PM EDT |
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No, I don’t think so. He’s a little big, maybe. (Clarified to if my brother has health issues.) |
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How old is your maternal grandmother? |
Question 07/23/20 3:26 PM EDT |
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Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. |
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How old is your maternal grandfather? |
Question 07/23/20 3:27 PM EDT |
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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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Any medical history for your paternal grandmother? |
Question 07/23/20 3:30 PM EDT |
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She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82. |
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Does your dad’s father have health issues? |
Question 07/23/20 3:30 PM EDT |
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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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Have you had any recent illness? |
Question 07/23/20 3:31 PM EDT |
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No. . . the last time I was sick was when I was having those heartburn problems a while ago. |
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Any fever? |
Question 07/23/20 3:32 PM EDT |
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I haven’t had a fever. |
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Any chills? |
Question 07/23/20 3:32 PM EDT |
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Nope, no chills. |
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Any acne? |
Question 07/23/20 3:32 PM EDT |
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I took something for my acne. . . tetracycline, I think, back in high school. Since then I’ve just washed my face, I haven’t used anything special. But my zits have gotten better, and I think it’s because I’m on birth control now. |
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Has your body hair improved? |
Question 07/23/20 3:32 PM EDT |
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I think I have a little less body hair than I used to. |
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Do your eyes feel itchy? |
Question 07/23/20 3:33 PM EDT |
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They haven’t been itchy lately at all. |
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Are you having any redness in your eyes? |
Question 07/23/20 3:33 PM EDT |
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My eyes haven’t been red lately. . . not since I came in with those allergies a while ago. |
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Are your eyes dry? |
Question 07/23/20 3:34 PM EDT |
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My eyes don’t feel dry. |
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Do you have any pain in your eyes? |
Question 07/23/20 3:34 PM EDT |
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I haven’t had any eye problems lately–I went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good. |
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Are you having any ear problems? |
Question 07/23/20 3:34 PM EDT |
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My ears feel fine. |
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Any changes in your hearing? |
Question 07/23/20 3:36 PM EDT |
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My hearing is good. |
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Any ear pain? |
Question 07/23/20 3:36 PM EDT |
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My ears feel fine. |
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Ear drainage? (Clarified to Do you have drainage from your ears?.) |
Question 07/23/20 3:36 PM EDT |
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Nothing is coming out of my ears. (Clarified to if I have ear drainage.) |
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Any changes in your sense of smell? |
Question 07/23/20 3:46 PM EDT |
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No. |
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Does any nose bleed? |
Question 07/23/20 3:47 PM EDT |
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Nope, my nose isn’t bleeding at all. |
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Any sinus pressure? |
Question 07/23/20 3:47 PM EDT |
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My sinuses have been fine. |
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Has your sense of taste changed? |
Question 07/23/20 3:47 PM EDT |
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No, I think my sense of taste is fine. |
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Are you having dry mouth? |
Question 07/23/20 3:48 PM EDT |
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My mouth hasn’t been dry. |
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ANY pain in your mouth? |
Question 07/23/20 3:48 PM EDT |
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No, my mouth feels fine. |
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ANY sore throat? |
Question 07/23/20 3:49 PM EDT |
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No, it’s fine. |
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Any issue with your gums? |
Question 07/23/20 3:49 PM EDT |
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My gums have been fine. |
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Any issue with your tongue? |
Question 07/23/20 3:49 PM EDT |
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My tongue feels fine. |
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Any difficulties when swallowing? |
Question 07/23/20 3:50 PM EDT |
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I can swallow fine. |
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SORE throat? |
Question 07/23/20 3:50 PM EDT |
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No, it’s fine. |
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Any voice changes? |
Question 07/23/20 3:50 PM EDT |
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My voice has been fine. |
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Any swollen lymph nodes? |
Question 07/23/20 3:52 PM EDT |
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My lymph nodes seem fine. |
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Are you having any nausea? |
Question 07/23/20 3:52 PM EDT |
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No, I haven’t been nauseous at all. |
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Any vomiting? |
Question 07/23/20 3:53 PM EDT |
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No. |
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ANY pain in the abdomen? |
Question 07/23/20 3:53 PM EDT |
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I haven’t really had any stomach problems since I came in with them a while ago. |
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Any constipation? |
Question 07/23/20 3:53 PM EDT |
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I don’t have that problem. |
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Any diarrhea? |
Question 07/23/20 3:54 PM EDT |
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I haven’t had any problems with diarrhea. |
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Excessive flatulence? |
Question 07/23/20 3:54 PM EDT |
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I haven’t been having any gas lately. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. |
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flatulence is one of the side effect of metformin |
Educate 07/23/20 3:55 PM EDT |
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Thanks for telling me. |
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Any food intolerance |
Question 07/23/20 3:56 PM EDT |
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I can eat just about anything. |
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Any burning sensation when you urinate? |
Question 07/23/20 3:56 PM EDT |
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No, it doesn’t burn when I pee. |
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Any blood in your urine? |
Question 07/23/20 3:57 PM EDT |
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No! That doesn’t sound like it would be good. |
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Are you having any pain right now? |
Question 07/23/20 3:57 PM EDT |
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I don’t have any pain anywhere. |
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Any vaginal discharge? |
Question 07/23/20 3:58 PM EDT |
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My discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish. |
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Any vaginal itching? |
Question 07/23/20 3:58 PM EDT |
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No, it feels normal. |
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Do you have any problem with your breasts? |
Question 07/23/20 3:59 PM EDT |
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No, my breasts feel fine. |
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Any pain in the breasts? |
Question 07/23/20 3:59 PM EDT |
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No, my breasts feel fine. |
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Are you having any dizziness/ |
Question 07/23/20 3:59 PM EDT |
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I haven’t been getting dizzy at all. |
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Any lightheadedness? |
Question 07/23/20 4:00 PM EDT |
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No, I don’t really get lightheaded. |
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Any tingling? |
Question 07/23/20 4:00 PM EDT |
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Nope, no tingling. |
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Any loss of balance? |
Question 07/23/20 4:00 PM EDT |
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My balance is fine. |
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Any changes in sensation? |
Question 07/23/20 4:00 PM EDT |
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I haven’t noticed any changes. |
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Any seizures? |
Question 07/23/20 4:01 PM EDT |
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No, I’ve still never had problems with seizures, fortunately. |
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Do you have memory problems? |
Question 07/23/20 4:01 PM EDT |
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I think my memory has been fine. |
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Any muscle pain? |
Question 07/23/20 4:01 PM EDT |
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My muscles have felt great, especially since I started exercising more. |
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Joint pain? |
Question 07/23/20 4:02 PM EDT |
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My joints always seem fine. |
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Any muscle weakness? |
Question 07/23/20 4:02 PM EDT |
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No, I haven’t felt weak at all. |
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Any swelling? |
Question 07/23/20 4:03 PM EDT |
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Nothing is swollen. |
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Performed pulse oximetry |
Exam Action 07/24/20 10:01 AM EDT |
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Performed spirometry |
Exam Action 07/24/20 10:01 AM EDT |
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Inspected scalp |
Exam Action 07/24/20 10:01 AM EDT |
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Inspected scalp |
Exam Action 07/24/20 10:01 AM EDT |
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Inspected hair on scalp |
Exam Action 07/24/20 10:01 AM EDT |
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Inspected scalp |
Exam Action 07/24/20 10:01 AM EDT |
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Inspected right eyebrow and orbital area |
Exam Action 07/24/20 10:02 AM EDT |
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Inspected left eyebrow and orbital area |
Exam Action 07/24/20 10:02 AM EDT |
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Inspected mouth: Oral mucosa moist. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation |
Exam Action 07/24/20 10:02 AM EDT |