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
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05/29/20 7:58 PM EDT
Inspected nose and mouth
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05/29/20 7:58 PM EDT
Inspected left side of face
Exam Action
05/29/20 7:58 PM EDT
Inspected back of head
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05/29/20 7:58 PM EDT
Inspected right side of face
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05/29/20 7:58 PM EDT
Inspected general face
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05/29/20 7:58 PM EDT
Inspected right side of face
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05/29/20 7:58 PM EDT
Inspected general face
Exam Action
05/29/20 7:58 PM EDT
Inspected nose and mouth
Exam Action
05/29/20 7:58 PM EDT
Inspected forehead and scalp
Exam Action
05/29/20 7:58 PM EDT
Inspected nose and mouth
Exam Action
05/29/20 7:58 PM EDT
Inspected right orbital area and sclera
Exam Action
05/29/20 7:59 PM EDT
Inspected lower conjunctiva
Exam Action
05/29/20 7:59 PM EDT
Inspected upper conjunctiva
Exam Action
05/29/20 8:00 PM EDT
Inspected upper conjunctiva
Exam Action
05/29/20 8:00 PM EDT
Inspected left orbital area and sclera
Exam Action
05/29/20 8:00 PM EDT
Performed otoscopic examination of right naris
Exam Action
05/29/20 8:00 PM EDT
Performed otoscopic examination of left naris
Exam Action
05/29/20 8:01 PM EDT
Performed otoscopic examination of right ear
Exam Action
05/29/20 8:02 PM EDT
Performed otoscopic examination of left ear
Exam Action
05/29/20 8:02 PM EDT
Inspected mouth
Exam Action
05/29/20 8:03 PM EDT
Inspected mouth: pushed tongue left with tongue blade
Exam Action
05/29/20 8:04 PM EDT
Inspect mouth: pushed tongue right with tongue blade
Exam Action
05/29/20 8:04 PM EDT
Inspect mouth: lifted tongue with tongue blade
Exam Action
05/29/20 8:04 PM EDT
Inspected mouth: depressed tongue with tongue blade
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05/29/20 8:04 PM EDT
Inspected front of neck
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05/29/20 8:06 PM EDT
Inspected left side of neck
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05/29/20 8:06 PM EDT
Inspected back of neck
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05/29/20 8:06 PM EDT
Inspected right side of neck
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05/29/20 8:06 PM EDT
Inspected back of neck
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05/29/20 8:06 PM EDT
Inspected right side of neck
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05/29/20 8:07 PM EDT
Inspected front of neck
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05/29/20 8:07 PM EDT
Inspected right side of neck
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05/29/20 8:07 PM EDT
Inspected front of neck
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05/29/20 8:07 PM EDT
Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported
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05/29/20 8:07 PM EDT
Palpated maxillary sinuses: No tenderness reported
Exam Action
05/29/20 8:08 PM EDT
Palpated frontal sinuses: No tenderness reported
Exam Action
05/29/20 8:08 PM EDT
Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+
Exam Action
05/29/20 8:08 PM EDT
Palpated right carotid artery: No thrill, 2+
Exam Action
05/29/20 8:10 PM EDT
Palpated left carotid artery: No thrill, 2+
Exam Action
05/29/20 8:10 PM EDT
Palpated jaw: Full range of motion, no popping or clicking
Exam Action
05/29/20 8:11 PM EDT
Palpated axillary lymph nodes: Not palpable
Exam Action
05/29/20 8:11 PM EDT
Palpated supraclavicular lymph nodes: Not palpable
Exam Action
05/29/20 8:12 PM EDT
Palpated lymph nodes of head and neck: Not palpable
Exam Action
05/29/20 8:12 PM EDT
Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported
Exam Action
05/29/20 8:12 PM EDT
Auscultated breath sounds in anterior right lower lobe
Exam Action
05/29/20 8:13 PM EDT
Auscultated breath sounds in anterior right middle lobe
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05/29/20 8:13 PM EDT
Auscultated breath sounds in anterior right upper lobe
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05/29/20 8:13 PM EDT
Auscultated breath sounds in anterior left upper lobe
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05/29/20 8:13 PM EDT
Auscultated breath sounds in anterior left mid-chest (upper lobe)
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05/29/20 8:13 PM EDT
Auscultated breath sounds in anterior left lower lobe
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05/29/20 8:13 PM EDT
Auscultated breath sounds in posterior left upper lobe
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05/29/20 8:13 PM EDT
Auscultated breath sounds in posterior left mid-back (lower lobe)
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05/29/20 8:13 PM EDT
Auscultated breath sounds in posterior left lower lobe
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05/29/20 8:13 PM EDT
Auscultated breath sounds in posterior left lower lobe on side
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05/29/20 8:13 PM EDT
Auscultated breath sounds in posterior left lower lobe near spine
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05/29/20 8:13 PM EDT
Auscultated breath sounds in posterior right lower lobe near spine
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05/29/20 8:14 PM EDT
Auscultated breath sounds in posterior right lower lobe on side
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05/29/20 8:14 PM EDT
Auscultated breath sounds in posterior right lower lobe
Exam Action
05/29/20 8:14 PM EDT
Auscultated breath sounds in posterior right mid-back (lower lobe)
Exam Action
05/29/20 8:14 PM EDT
Auscultated breath sounds in posterior right upper lobe
Exam Action
05/29/20 8:14 PM EDT
Auscultated right temporal pulse
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05/29/20 8:14 PM EDT
Auscultated left temporal pulse
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05/29/20 8:14 PM EDT
Auscultated right carotid pulse
Exam Action
05/29/20 8:15 PM EDT
Auscultated left carotid pulse
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05/29/20 8:15 PM EDT
Tested left pupillary reaction with penlight
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05/29/20 8:16 PM EDT
Tested right pupillary reaction with penlight
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05/29/20 8:16 PM EDT
Follow my finger with just your eyes
Question
05/29/20 8:17 PM EDT
Ok.
Tested EOM to the upper right
Exam Action
05/29/20 8:17 PM EDT
Tested EOM to the lower right
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05/29/20 8:17 PM EDT
Tested EOM to the lower center
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05/29/20 8:17 PM EDT
Tested convergence to the center
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05/29/20 8:17 PM EDT
Tested EOM to the upper center
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05/29/20 8:17 PM EDT
Tested EOM to the upper left
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05/29/20 8:17 PM EDT
Tested EOM to the lower left
Exam Action
05/29/20 8:17 PM EDT
Tell me when you can no loner see
Question
05/29/20 8:18 PM EDT
Ok, I will.
Tested peripheral vision
Exam Action
05/29/20 8:18 PM EDT
Now.
Examined fundus of right eye with ophthalmoscope
Exam Action
05/29/20 8:20 PM EDT
Examined fundus of left eye with ophthalmoscope
Exam Action
05/29/20 8:21 PM EDT
F P
Is the volume the same in both ears or louder in one ear
Question
05/29/20 8:24 PM EDT
Ok.
Same in both ears.
Performed Weber test with tuning fork
Exam Action
05/29/20 8:25 PM EDT
Tell me when you no longer hear the ringing
Question
05/29/20 8:25 PM EDT
Ok, I will.
Now.
F.
Question
05/29/20 8:26 PM EDT
F.
Eight
Question
05/29/20 8:26 PM EDT
Eight.
W.
Question
05/29/20 8:26 PM EDT
W.
Performed whisper test in right ear
Exam Action
05/29/20 8:26 PM EDT
Four
Question
05/29/20 8:26 PM EDT
Four.
R.
Question
05/29/20 8:26 PM EDT
R.
Nine.
Question
05/29/20 8:26 PM EDT
Nine.
Performed whisper test in left ear
Exam Action
05/29/20 8:27 PM EDT
Tested gag reflex with tongue blade
Exam Action
05/29/20 8:27 PM EDT
