Tina Jones Health History transcript, documentation and objective data
Tina Jones Health History transcript, documentation and objective data
Transcript
Started: Jul 17, 2022 | Total Time: 189 min
All Lines (161)Interview Questions (144)Statements (5)Exam Actions (12)
Height: 170 cm
Exam Action
07/17/22 1:35 AM MDT
Weight: 90 kg
Exam Action
07/17/22 1:35 AM MDT
BMI: 31
Exam Action
07/17/22 1:35 AM MDT
Random blood glucose: 238
Exam Action
07/17/22 1:35 AM MDT
Temperature: 101.1 F
Exam Action
07/17/22 1:35 AM MDT
Blood pressure: 142/82
Exam Action
07/17/22 1:35 AM MDT
Respiratory rate: 19
Exam Action
07/17/22 1:35 AM MDT
O2 sat: 99%
Exam Action
07/17/22 1:35 AM MDT
Heart rate: 86
Exam Action
07/17/22 1:35 AM MDT
Hello Tina my name is xxx and I’m your nurse today
Greet
07/17/22 1:35 AM MDT
Hey.
Can you confirm your name
Question
07/17/22 1:35 AM MDT
Tina Jones.
ORDER HERE
What brings you in today
Question
07/17/22 1:36 AM MDT
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! Tina Jones Health History transcript, documentation and objective data
I am so sorry you’re going through that
Empathize
07/17/22 1:36 AM MDT
Thanks for understanding.
What additional symptoms have you experienced (Clarified to Do you have any other symptoms?.)
Question
07/17/22 1:36 AM MDT
I mean, it’s all red and swollen, and there’s pus, it feels hot, it hurts like hell… It’s got all that going on. (Clarified to if I have other symptoms.)
Can you rate your current pain level on a scale of zero to ten
Question
07/17/22 1:37 AM MDT
I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.
What pain pills have you taken
Question
07/17/22 1:37 AM MDT
It’s called tramadol.
What dose of Tramadol
Question
07/17/22 1:37 AM MDT
I’m not 100% sure, but I think they’re 50 milligrams.
How often do you take Tramadol
Question
07/17/22 1:37 AM MDT
I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
When was the last time you took Tramadol
Question
07/17/22 1:38 AM MDT
This morning I took two pain pills right before I came here, at around 8:30.
Does a Tramadol typically work for your pain Tina Jones Health History transcript, documentation and objective data
Question
07/17/22 1:38 AM MDT
Yeah, the pain pills help, but only for a few hours.
Can you describe your pain
Question
07/17/22 1:38 AM MDT
It’s throbbing and like, sharp if I try to put weight on it.
How did you hurt your foot
Question
07/17/22 1:38 AM MDT
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.
How’s your foot been draining any liquids
Question
07/17/22 1:39 AM MDT
Yeah, there’s definitely pus.
What color is the pus
Question
07/17/22 1:39 AM MDT
It’s… white or maybe off-white.
What have you done to treat your foot after the accident (Clarified to How have you been treating your foot?.)
Question
07/17/22 1:39 AM MDT
I made sure to clean it and just keep it bandaged. And I put Neosporin on it. (Clarified to what I did for my foot at home.)
How effective was the Neosporin
Question
07/17/22 1:40 AM MDT
Well, I had to come back to get my foot checked out even though I used the ointment. [AUDIO COMING SOON]
Are you able to walk
Question
07/17/22 1:40 AM MDT
No, I can’t. I can’t put any weight on it without like, shooting pain.
What pre-existing medical conditions do you have
Question
07/17/22 1:42 AM MDT
Well, in terms of general health stuff, I have asthma and diabetes.
When were you diagnosed with diabetes
Question
07/17/22 1:42 AM MDT
I was diagnosed when I was 24.
What medications did you take for your diabetes
Question
07/17/22 1:42 AM MDT
It was Metformin.
Do you still currently take Metformin
Question
07/17/22 1:42 AM MDT
I don’t take anything for my diabetes anymore.
What made you start taking medication for your diabetes (Clarified to What made you stop taking your diabetes medication?.)
Question
07/17/22 1:43 AM MDT
I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I’m just eating healthier than I did when I was taking the pills. (Clarified to what happened that caused me to stop taking my diabetes medication.)
Diabetes is a very serious condition that has to be treated very carefully
Educate
07/17/22 1:44 AM MDT
Sure, I think I understand what you mean.
Do you monitor your blood glucose
Question
07/17/22 1:44 AM MDT
I have a monitor at home, but to be honest I don’t really use it that often. It’s such a hassle to check my blood sugar, and my diabetes is under control right now so I don’t really need to.
What is your current diet like
Question
07/17/22 1:44 AM MDT
It’s pretty good, I think. I’m not a huge health nut or anything.
Have you had any change in your appetite
Question
07/17/22 1:45 AM MDT
Yeah, lately I’ve definitely been much hungrier than usual.
Has there been any change in your weight
Question
07/17/22 1:45 AM MDT
Yeah, I’ve lost some weight recently.
How frequently do you urinate
Question
07/17/22 1:45 AM MDT
I don’t know. Every hour or two when I’m awake?
Documentation / Electronic Health Record
Document: Provider Notes
Document: Provider Notes
Student Documentation
Model Documentation
Identifying Data & Reliability
Ms. Tina Jones is a pleasant 28 year old African American female who presents to the clinic today to establish primary care. She also has a complaint of a right foot injury that occurred during a fall that happened two days ago. She is the primary and sole source of the interview. She is very knowledgable and easy to comprehend. She is alert and oriented X 4 and maintains eye contact throughout the interview Tina Jones Health History transcript, documentation and objective data.
Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
General Survey
Ms. Jones is alert and oriented. She answers questions accurately and is dressed appropriately. She doesnt exhibit any strange speech or behaviors. She doesnt appear to be under any distress.
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
Chief Complaint
Scrape on right foot with pain and symptoms of infection
“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!”
History Of Present Illness
Ms. Jones greater foot about a week ago while being outside barefoot. She reported to the ER the night she injured her foot, where they gave her a prescription for Tramadol and treated the wound. She also received an x-ray. Her symptoms began to worsen two days ago. She began to notice increased pain, purulent drainage, warmth and swelling around the wound. She’s unable to put weight on the injured foot without sharp shooting pain. She has been changing the bandage and cleaning the wound with soap and water twice-daily. She also reports using Neosporin and peroxide occasionally.
Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been…
Objective Data Collection: 1 of 1 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips.
Found:
Indicates an item that you found.
Available:
Indicates an item that is available to be found.
Tina Jones Health History transcript, documentation and objective data
Category
Scored Items
Experts selected these examinations as essential components of objective data collection for this patient.
Patient Data
Not Scored
Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient’s case.
Wound Treatment
ORDER NOW
Finding:
Inspected wound
Finding:
Measured wound: 2 cm x 1.5 cm, 2.5 mm deep
(Found)
Pro Tip: Measuring a patient’s wound will help you track whether it worsens or heals in future visits.
Example Question:
Finding:
Swabbed wound and sent to lab for C & S
(Found)
Pro Tip: Sending a culture of wound drainage to a medical lab will help you choose the best antibiotic for that microbe type, and can rule out dangerous infections such as MRSA.
Example Question:
Finding:
Cleansed and irrigated wound with normal saline and applied dry sterile dressing Tina Jones Health History transcript, documentation and objective data.
