Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
Transcript
All Lines (645)Interview Questions (210)Statements (41)Exam Actions (394)
| Hello, my name is . I will be conducting an interview and later perform a physical exam. | Greet 07/22/20 5:37 PM EDT | |
| Hey. | ||
| What is your name? | Question 07/22/20 5:37 PM EDT | |
| Tina Jones. | ||
| Your date of birth? | Question 07/22/20 5:37 PM EDT | |
| February 17th. | ||
| How old are you?
|
Question 07/22/20 5:43 PM EDT | |
| I’m 28. | ||
| What brought you into the clinic today? | Question 07/22/20 5:43 PM EDT | |
| I came in because I’m required to have a recent physical exam for the health insurance at my new job. | ||
| Do you have any current health problem? | Question 07/22/20 5:44 PM EDT | |
| 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. | ||
| What is your new job? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation | Question 07/22/20 5:44 PM EDT | |
| 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! | ||
| That is great. | Empathize 07/22/20 5:45 PM EDT | |
| Thanks. | ||
| When was your last physical exam? | Question 07/22/20 5:45 PM EDT | |
| 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. | ||
| What did your gynecologist say? | Question 07/22/20 5:45 PM EDT | |
| 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. | ||
| How often do you take birth control? | Question 07/22/20 5:48 PM EDT | |
| I take it every morning, with breakfast. | ||
| What is the name of the birth control pill you took? | Question 07/22/20 5:49 PM EDT | |
| They’re called Yaz. | ||
| Has your menstrual cycle improved since taking Yaz? | Question 07/22/20 5:50 PM EDT | |
| Now that I’m on the pill I’m getting my period every month. | ||
| That is great. I am glad you are having your period every month. | Empathize 07/22/20 5:50 PM EDT | |
| Thanks. | ||
| How long have you had asthma. | Question 07/22/20 5:51 PM EDT | |
| I’ve had asthma a long time. . . since I was really little. | ||
| What age were you diagnosed with asthma? | Question 07/22/20 5:51 PM EDT | |
| 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. | ||
| I am sorry about the experience. | Empathize 07/22/20 5:52 PM EDT | |
| Thanks. | ||
| How do you manage your asthma? | Question 07/22/20 5:52 PM EDT | |
| I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. | ||
| What are your triggers for asthma? | Question 07/22/20 5:53 PM EDT | |
| 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. | ||
| It is important to stay away from triggers. | Educate 07/22/20 5:54 PM EDT | |
| Thanks for telling me. | ||
| What happens when you are around dust? | Question 07/22/20 5:54 PM EDT | |
| 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. | ||
| What inhaler do you use? | Question 07/22/20 5:59 PM EDT | |
| The daily inhaler is Flovent, and the rescue inhaler is Proventil. | ||
| How often do you use flovent? | Question 07/22/20 6:00 PM EDT | |
| Twice a day. | ||
| When did you most recently use the flovent inhaler? | Question 07/22/20 6:01 PM EDT | |
| I use my Flovent inhaler two times a day. | ||
| When did you last use your inhaler? | Question 07/22/20 6:03 PM EDT | |
| 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. | ||
| How much Albuterol do you use? | Question 07 |
| 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. | ||
| What is your relationship like with your family? | Question 07/22/20 7:39 PM EDT | |
| 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. | ||
| That is great. | Empathize 07/22/20 7:39 PM EDT | |
| Thanks. | ||
| Are you involved in church? | Question 07/22/20 7:39 PM EDT | |
| 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. | ||
| Are you feeling stressed? | Question 07/22/20 7:40 PM EDT | |
| I’m actually feeling really good lately. . . not stressed at all. | ||
| How do you cope with stress? | Question 07/22/20 7:40 PM EDT | |
| 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. | ||
| That is good to hear. | Empathize 07/22/20 7:40 PM EDT | |
| Thanks. | ||
| Are you feeling depressed? | Question 07/22/20 7:41 PM EDT | |
| No, I’m actually feeling really good these days. | ||
| How do you feel about your life? | Question 07/22/20 7:41 PM EDT | |
| 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. | ||
| Are you feeling anxious? | Question 07/22/20 7:41 PM EDT | |
| I guess I had anxiety back when I was having those sleep problems. . . I’ve been feeling much better lately, though. | ||
| Do you have sleeping problems? | Question 07/22/20 7:42 PM EDT | |
| I’m sleeping a lot better now, which is a relief. | ||
| Good to hear. | Empathize 07/22/20 7:42 PM EDT | |
| Thanks. | ||
| How many hours are you sleeping a night? | Question 07/22/20 7:42 PM EDT | |
| I’m usually asleep by 11:30, and I wake up at 8, so. . . about 8 or 9 hours a night. | ||
| That is great. | Empathize 07/22/20 7:42 PM EDT | |
| Thanks. | ||
| Have you ever smoked tobacco? | Question 07/22/20 7:43 PM EDT | |
| No. I think it’s gross. | ||
| Have you ever used cocaine? | Question 07/22/20 7:43 PM EDT | |
| No way, I have no interest in that. That stuff can mess you up. | ||
| Have you ever used heroin? | Question 07/22/20 7:49 PM EDT | |
| Uh, no. | ||
| Have you ever used illegal drugs? | Question 07/23/20 3:17 PM EDT | |
| Well, I used to smoke pot. . . but I don’t do that anymore. | ||
| What was the last time you smoked pot? | Question 07/23/20 3:17 PM EDT | |
| I haven’t smoked pot since I was twenty or twenty-one. | ||
| Do you have any family history of mental illness? | Question 07/23/20 3:18 PM EDT | |
| No. They’re crazy, but nobody’s diagnosed with anything. | ||
| Have you had suicidal thoughts? | Question 07/23/20 3:19 PM EDT | |
| No, I’ve never done that. | ||
| Any new family medical history report? | Question 07/23/20 3:20 PM EDT | |
| My mom has some issues, and I think some of my grandparents did, too. | ||
| How old is your mom? | Question 07/23/20 3:21 PM EDT | |
| Mom is 50. | ||
| What medical problems does your mum have? | Question 07/23/20 3:21 PM EDT | |
| Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. | ||
| What medical problems did your father have? | Question 07/23/20 3:22 PM EDT | |
| He had high blood pressure and cholesterol, and diabetes too…the same kind as me. | ||
| How old is your brother? | Question 07/23/20 3:24 PM EDT | |
| He’s almost 27. | ||
| Does he have any medical issue? (Clarified to Does your younger sister have health problems?.) | Question 07/23/20 3:25 PM EDT | |
| She’s pretty healthy. She has asthma too, but she almost never has attacks. (Clarified to if my younger sister has health problems.) | ||
| Does your bother have health issues? (Clarified to Does your brother have medical problems?.) | Question 07/23/20 3:25 PM EDT | |
| No, I don’t think so. He’s a little big, maybe. (Clarified to if my brother has health issues.) | ||
| How old is your maternal grandmother? | Question 07/23/20 3:26 PM EDT | |
| Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. | ||
| How old is your maternal grandfather? | Question 07/23/20 3:27 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. | ||
| Any medical history for your paternal grandmother? | Question 07/23/20 3:30 PM EDT | |
| She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82. | ||
| Does your dad’s father have health issues? | Question 07/23/20 3:30 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. | ||
| Have you had any recent illness? | Question 07/23/20 3:31 PM EDT | |
| No. . . the last time I was sick was when I was having those heartburn problems a while ago. | ||
| Any fever? | Question 07/23/20 3:32 PM EDT | |
| I haven’t had a fever. | ||
| Any chills? | Question 07/23/20 3:32 PM EDT | |
| Nope, no chills. | ||
| Any acne? | Question 07/23/20 3:32 PM EDT | |
| 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. | ||
| Has your body hair improved? | Question 07/23/20 3:32 PM EDT | |
| I think I have a little less body hair than I used to. | ||
| Do your eyes feel itchy? | Question 07/23/20 3:33 PM EDT | |
| They haven’t been itchy lately at all. | ||
| Are you having any redness in your eyes? | Question 07/23/20 3:33 PM EDT | |
| My eyes haven’t been red lately. . . not since I came in with those allergies a while ago. | ||
| Are your eyes dry? | Question 07/23/20 3:34 PM EDT | |
| My eyes don’t feel dry. | ||
| Do you have any pain in your eyes? | Question 07/23/20 3:34 PM EDT | |
| 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. | ||
| Are you having any ear problems? | Question 07/23/20 3:34 PM EDT | |
| My ears feel fine. | ||
| Any changes in your hearing? | Question 07/23/20 3:36 PM EDT | |
| My hearing is good. | ||
| Any ear pain? | Question 07/23/20 3:36 PM EDT | |
| My ears feel fine. | ||
| Ear drainage? (Clarified to Do you have drainage from your ears?.) | Question 07/23/20 3:36 PM EDT | |
| Nothing is coming out of my ears. (Clarified to if I have ear drainage.) | ||
| Any changes in your sense of smell? | Question 07/23/20 3:46 PM EDT | |
| No. | ||
| Any nose bleeds? | Question 07/23/20 3:47 PM EDT | |
| Nope, my nose isn’t bleeding at all. | ||
| Any sinus pressure? | Question 07/23/20 3:47 PM EDT | |
| My sinuses have been fine. | ||
| Has your sense of taste changed? | Question 07/23/20 3:47 PM EDT | |
| No, I think my sense of taste is fine. | ||
| Are you having dry mouth? | Question 07/23/20 3:48 PM EDT | |
| My mouth hasn’t been dry. | ||
| ANY pain in your mouth? | Question 07/23/20 3:48 PM EDT | |
| No, my mouth feels fine. | ||
| ANY sore throat? | Question 07/23/20 3:49 PM EDT | |
| No, it’s fine. | ||
| Any issue with your gums? | Question 07/23/20 3:49 PM EDT | |
| My gums have been fine. | ||
| Any issue with your tongue? | Question 07/23/20 3:49 PM EDT | |
| My tongue feels fine. | ||
| Any difficulties when swallowing? | Question 07/23/20 3:50 PM EDT | |
| I can swallow fine. | ||
| SORE throat? | Question 07/23/20 3:50 PM EDT | |
| No, it’s fine. | ||
| Any voice changes? | Question 07/23/20 3:50 PM EDT | |
| My voice has been fine. | ||
| Any swollen lymph nodes? | Question 07/23/20 3:52 PM EDT | |
| My lymph nodes seem fine. | ||
| Are you having any nausea? | Question 07/23/20 3:52 PM EDT | |
| No, I haven’t been nauseous at all. | ||
| Any vomiting? | Question 07/23/20 3:53 PM EDT | |
| No. | ||
| ANY pain in the abdomen? | Question 07/23/20 3:53 PM EDT | |
| I haven’t really had any stomach problems since I came in with them a while ago. | ||
| Any constipation? | Question 07/23/20 3:53 PM EDT | |
| I don’t have that problem. | ||
| Any diarrhea? | Question 07/23/20 3:54 PM EDT | |
| I haven’t had any problems with diarrhea. | ||
| Excessive flatulence? | Question 07/23/20 3:54 PM EDT | |
| 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. | ||
| flatulence is one of the side effect of metformin | Educate 07/23/20 3:55 PM EDT | |
| Thanks for telling me. | ||
| Any food intolerance | Question 07/23/20 3:56 PM EDT | |
| I can eat just about anything. | ||
| Any burning sensation when you urinate? | Question 07/23/20 3:56 PM EDT | |
| No, it doesn’t burn when I pee. | ||
| Any blood in your urine? | Question 07/23/20 3:57 PM EDT | |
| No! That doesn’t sound like it would be good. | ||
| Are you having any pain right now? | Question 07/23/20 3:57 PM EDT | |
| I don’t have any pain anywhere. | ||
| Any vaginal discharge? | Question 07/23/20 3:58 PM EDT | |
| My discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish. | ||
| Any vaginal itching? | Question 07/23/20 3:58 PM EDT | |
| No, it feels normal. | ||
| Do you have any problem with your breasts? | Question 07/23/20 3:59 PM EDT | |
| No, my breasts feel fine. | ||
| Any pain in the breasts? | Question 07/23/20 3:59 PM EDT | |
| No, my breasts feel fine. | ||
| Are you having any dizziness/ | Question 07/23/20 3:59 PM EDT | |
| I haven’t been getting dizzy at all. | ||
| Any lightheadedness? | Question 07/23/20 4:00 PM EDT | |
| No, I don’t really get lightheaded. | ||
| Any tingling? | Question 07/23/20 4:00 PM EDT | |
| Nope, no tingling. | ||
| Any loss of balance? | Question 07/23/20 4:00 PM EDT | |
| My balance is fine. | ||
| Any changes in sensation? | Question 07/23/20 4:00 PM EDT | |
| I haven’t noticed any changes. | ||
| Any seizures? | Question 07/23/20 4:01 PM EDT | |
| No, I’ve still never had problems with seizures, fortunately. | ||
| Do you have memory problems? | Question 07/23/20 4:01 PM EDT | |
| I think my memory has been fine. | ||
| Any muscle pain? | Question 07/23/20 4:01 PM EDT | |
| My muscles have felt great, especially since I started exercising more. | ||
| Joint pain? | Question 07/23/20 4:02 PM EDT | |
| My joints always seem fine. | ||
| Any muscle weakness? | Question 07/23/20 4:02 PM EDT | |
| No, I haven’t felt weak at all. | ||
| Any swelling? | Question 07/23/20 4:03 PM EDT | |
| Nothing is swollen. | ||
| Performed pulse oximetry | Exam Action 07/24/20 10:01 AM EDT | |
| Performed spirometry | Exam Action 07/24/20 10:01 AM EDT |
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