Health History Tina Jones Shadow health Transcript
Transcript
Started: May 24, 2020 | Total Time:350 min
Height: 170 cm
Exam Action
05/22/20 12:11 PM EDT
Weight: 90 kg
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BMI: 31
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Random blood glucose: 238
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Temperature: 101.1 F
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05/22/20 12:11 PM EDT
Blood pressure: 142/82
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05/22/20 12:11 PM EDT
Respiratory rate: 19
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05/22/20 12:11 PM EDT
O2 sat: 99%
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Heart rate: 86
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05/22/20 12:11 PM EDT
Hello. My name is Joan and I will be interviewing you today and later examine you.
Greet
05/22/20 12:12 PM EDT
Hey.
What is your name?
Question
05/22/20 12:12 PM EDT
Tina Jones.
Why are you here today?
Question
05/22/20 12:13 PM EDT
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!
Am sorry to hear that?
Empathize
05/22/20 12:13 PM EDT
I appreciate you saying that.
When did you get the scrape?
Question
05/22/20 12:14 PM EDT
Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
How severe is the pain?
Question
05/22/20 12:14 PM EDT
It’s really bad.
Can you describe the pain?
Question
05/22/20 12:15 PM EDT
It’s throbbing and like, sharp if I try to put weight on it.
Did you hurt any other part?
Question
05/22/20 12:15 PM EDT
No, I caught myself on the railing so I didn’t fall on the ground. Only my foot got hurt.
how has the pain changed over time?
Question
05/22/20 12:16 PM EDT
At first, it seemed like it was healing up fine and it didn’t give me a lot of pain. But the last two days, the pain got way worse.
Does the pain radiate anywhere else?
Question
05/22/20 12:17 PM EDT
The pain’s worse in my foot, but I feel it moving up into my ankle, too.
How painful is the ankle? (Clarified to How did you hurt your ankle?.)
Question
05/22/20 12:18 PM EDT
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. (Clarified to how I hurt my ankle.)
is it possible for you to stand on your foot?
Question
05/22/20 12:18 PM EDT
No, I can’t put weight on my foot without really sharp pain.
How do yo rate the pain on a scale of 0 o 10 (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)
Question
05/22/20 12:19 PM EDT
I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet. (Clarified to how I would rate my pain on a scale.)
can you tell me where the pain is located?
Question
05/22/20 12:19 PM EDT
It feels like the pain is just centered around the scrape, like around the ball of my foot. That’s where it hurts the most, but my whole foot feels some pain.
Which foot did you injure?
Question
05/22/20 12:20 PM EDT
My right foot.
Were you wearing shoes?
Question
05/22/20 12:20 PM EDT
Seems you love your work
Empathize
05/22/20 12:40 PM EDT
Thanks for saying that.
Do you have other health problems?
Question
05/22/20 12:40 PM EDT
Um, the only things I know I’m diagnosed with are diabetes. And asthma.
When were you diagnosed with asthma?
Question
05/22/20 12:42 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.
when dod you last have an asthma attack (Clarified to When was your last asthma attack?.)
Question
05/22/20 12:43 PM EDT
It’s really rare for me to have an attack now. Three days ago I had some breathing problems, but I guess probably my last full attack was in high school. (Clarified to when my last asthma attack was.)
How was your asthma when you were in high school?
Question
05/22/20 12:44 PM EDT
I was always a pretty average student. . . never the best, never the worst.
how do you know when you have asthma attack? (Clarified to What happens when you have an asthma attack?.)
Question
05/22/20 12:44 PM EDT
I haven’t had an asthma attack in a while, but I used to get them growing up, and my chest would feel really tight, like I couldn’t take in air, and I would wheeze really bad and get all sweaty. It was way worse than now, especially because I would use my inhaler and it wouldn’t help. It was really scary. (Clarified to to tell you about my asthma attacks.)
Do you get tight chest?
Question
05/22/20 12:45 PM EDT
Well. . . when my asthma gets bad my chest feels pretty tight, like I can’t take in air.
Do you get breathing difficult? (No matching questions found.)
Question
05/22/20 12:46 PM EDT
Do you get breathing difficulties during asthma attacks?
Question
05/22/20 12:46 PM EDT
I haven’t had a full attack in years, but when my breathing gets bad, I just use my inhaler.
What about wheezing? (Clarified to How is your wheezing?.)
Question
05/22/20 12:47 PM EDT
I’m not wheezing right now . . . But I did wheeze a little bit a few days ago at my cousin’s house. I had to use my inhaler. (Clarified to how my wheezing is.)
What do you use for your asthma? inhaler?
Question
05/22/20 12:48 PM EDT
It’s just a regular Proventil inhaler.
how many times do you use the inhaler?
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05/22/20 12:49 PM EDT
I don’t use it every day. Maybe two or three times a week. Although I guess lately, once I have to use it once, sometimes I need it again that day.
have you been been hospitalized for asthma?
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05/22/20 12:50 PM EDT
I went a bunch of times when I was little, for asthma attacks.
What else have you used for the asthma? (No matching questions found.)
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05/22/20 12:51 PM EDT
What else have you used for the asthma?what causes your asthma?
Question
05/22/20 12:51 PM EDT
When I used to have asthma attacks all the time, all different things could cause them. . . sometimes I couldn’t tell what was doing it. My breathing problems haven’t turned into a full attack in years, though.
What happens when you are around cats?
Question
05/22/20 12:52 PM EDT
Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up.
Do you have latex allergies?
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05/22/20 12:53 PM EDT
Nope.
Do you have food allergies?
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05/22/20 12:53 PM EDT
Nope, no food allergies that I know of.
are you allergic to dust?
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05/22/20 12:53 PM EDT
Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust.
Are you allergic to pollen ?
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05/22/20 12:54 PM EDT
Not that I’ve noticed.
are you allergic to mold?
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05/22/20 12:54 PM EDT
None that I know of.
Are you allergic to penicillin ?
Question
05/22/20 12:55 PM EDT
Yes.
what type of reaction do you have to penicillin?
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05/22/20 12:55 PM EDT
I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that.
Do you have other allergies?
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05/22/20 12:55 PM EDT
Well, besides cats, I’m allergic to penicillin.
any other seasonal asthma triggers?
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05/22/20 12:58 PM EDT
No, not really.
Any past asthma medications? (No matching questions found.)
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05/22/20 12:59 PM EDT
Any past asthma medications?When were you diagnosed of Diabetes? (Clarified to How old were you when you were diagnosed with diabetes?.)
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05/22/20 1:00 PM EDT
I was diagnosed when I was 24. (Clarified to when I was diagnosed with diabetes.)
What type of diabetes do you have?
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05/22/20 1:01 PM EDT
It’s type 2.
do you take any medication for diabetes?
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05/22/20 1:02 PM EDT
I don’t take anything for my diabetes anymore.
why did you stop? (Clarified to Why did you stop taking diabetes medication?.)
Question
05/22/20 1:02 PM EDT
I just got sick of dealing with it! (Clarified to why I stopped taking my diabetes medication.)
Were you unable to afford the medication? (No matching questions found.)
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05/22/20 1:02 PM EDT
WIts not advisable to stop medication without consulting your doctor, it can have negative effects?
Educate
05/22/20 1:04 PM EDT
Sure, I think I understand what you mean.
What diabetes medication were you taking?
Question
05/22/20 1:04 PM EDT
It was Metformin.
would you afford the metformin? (Clarified to Did you have issues affording the metformin?.)
Question
05/22/20 1:05 PM EDT
I haven’t had trouble affording medication . . . Cost wasn’t really the issue with the metformin. I just got really sick of having to take it, and I hated the side effects. [AUDIO COMING SOON] (Clarified to if I had problems affording the metformin.)
had you any other challenges accessing metformin? (No matching questions found.)
Question
05/22/20 1:06 PM EDT
what dosage of metformin were you taking?
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05/22/20 1:07 PM EDT
Honestly, I don’t remember what the dose was when I was taking it.
How many times were you taking metformin?
Question
05/22/20 1:07 PM EDT
I think it was one pill, twice a day.
when did you stop taking metformin?
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05/22/20 1:08 PM EDT
About three years ago, honestly.
when did you start taking metformin?
Question
05/22/20 1:09 PM EDT
When I was 24, right after I was first diagnosed.
did you tell your doctor that you stopped taking metformin?
Question
05/22/20 1:10 PM EDT
No, I just stopped taking it because I was sick of dealing with taking it everyday and feeling gassy all the time.
Its good to have a plan with the doctor before stopping medication
Educate
05/22/20 1:11 PM EDT
OK, I understand.
How old are you now?
Question
05/22/20 1:11 PM EDT
I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets.
How is your appetite?
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05/22/20 1:31 PM EDT
My appetite’s been huge lately. . . I feel like I’m hungry all the time.
Do you notice any change in weight?
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05/22/20 1:31 PM EDT
Yeah, I’ve lost some weight recently.
Are you trying to lose weight?
Question
05/22/20 1:31 PM EDT
No, I’m not trying to lose weight, but I did lose a little recently without meaning to. About ten pounds in the last month. [AUDIO COMING SOON]
Do you have hypertension?
Question
05/22/20 1:32 PM EDT
No, I’ve never been diagnosed with blood pressure problems.
Do you check your blood pressure regularly?
Question
05/22/20 1:33 PM EDT
I almost never check it. I mean, maybe twice a year I might? It’s not something I think about.
do you know your blood pressure range?
Question
05/22/20 1:33 PM EDT
It’s . . . oh, I don’t remember exactly because I never write it down. Let me try to remember . . . I feel like it’s usually around 140. And the bottom number is 80 or 90. I do know the last time in the ER it was something like 141/92. They said it was on the high side. [AUDIO COMING SOON]
The standard rate reading 12 120/80. Sure that on the higher side, you need to monitor it as well.
Educate
05/22/20 1:35 PM EDT
Alright, thanks for letting me know.
When did you have your last immunization?
Question
05/22/20 1:37 PM EDT
I think the last time I got shots was when I enrolled in college the first time. Oh, and I got a tetanus booster about a year ago.
Have you received the influenza vaccine ?
Question
05/22/20 1:38 PM EDT
No.
Did you complete your childhood immunizations? (Clarified to Are you up to date on immunizations?.)
Question
05/22/20 1:39 PM EDT
I’m pretty sure they are all taken care of. (Clarified to if I am up to date on shots.)
Do you use over the counter medications?
Question
05/22/20 1:41 PM EDT
I take Tylenol for a headache sometimes, or Advil for cramps, but not often.
What dosage of tylenol?
Question
05/22/20 1:41 PM EDT
I just take one or two of the 500 mg acetaminophen. I usually get the headaches at night from reading — squinting I guess — and so I take one or two and go to bed. [AUDIO COMING SOON]
what dosage of advil do you take?
Question
05/22/20 1:42 PM EDT
I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON]
How long have you been taking tramadol ?
Question
05/22/20 1:44 PM EDT
I started needing them two days ago.
when did you take the last tramadol?
Question
05/22/20 1:44 PM EDT
This morning I took two pain pills right before I came here, at around 8:30.
Do you take vitamin supplements?
Question
05/22/20 1:46 PM EDT
I don’t take vitamins or supplements.
Do you take herbal drugs? (Clarified to Do you take any herb supplements?.)
Question
05/22/20 1:46 PM EDT
No, I don’t take anything herbal. (Clarified to if I take herbal supplements.)
What is your highest level of educations?
Question
05/22/20 1:47 PM EDT
Well, I’m finishing up my Bachelor’s degree right now.
How is college life? (Clarified to Is college a stressful time?.)
Question
05/22/20 1:48 PM EDT
I don’t get stressed out much, but sometimes having such a hectic schedule can be a lot. Right now, though, I’m mostly worried about my foot. (Clarified to if college is stressful.)
Do you have financial problems accessing education ?
Question
05/22/20 1:49 PM EDT
I’m doing okay–I earn a pretty good wage at my job, but I do have to be careful with money since I’m still paying tuition. Right now I’m lucky to be able to save some money by living at my Mom’s house instead of paying rent.
Any financial problems accessing healthcare?
Question
05/22/20 1:50 PM EDT
I’m doing okay–I earn a pretty good wage at my job, but I do have to be careful with money since I’m still paying tuition. Right now I’m lucky to be able to save some money by living at my Mom’s house instead of paying rent.
Great, its good to continue with education nd also save money when you can.
Educate
05/22/20 1:51 PM EDT
OK, I understand.
What is your major at the college?
Question
05/22/20 1:52 PM EDT
I’m going to get my bachelor’s in accounting.
Do you have a belief system?
Question
05/22/20 1:53 PM EDT
Yeah. We go to First Baptist, and we do a lot with our church community. Even before a service, it’s pretty social; we go early so we can meet and talk with everybody. And I go to the Wednesday night Bible study group. There’s other events, too, pot-lucks, all of that. Oh, and once a month the church organizes like a volunteer event, so I try to do that. We spend a lot of time with our church family.
sounds like you have great social and religious conections
Empathize
05/22/20 1:54 PM EDT
I appreciate you telling me that.
Do you smoke tobacco?
Question
05/22/20 1:54 PM EDT
No. I think it’s gross.
Do you hang around people who smoke?
Question
05/22/20 1:55 PM EDT
Yeah, a couple of my friends smoke when we go out. I don’t like being around smokers, though.
Its good to avoid smoke, it is not good for asthma
Educate
05/22/20 1:55 PM EDT
That makes sense.
Do you smoke marijuana?
Question
05/22/20 1:56 PM EDT
Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.
how old were you then? (No matching questions found.)
Question
05/22/20 1:57 PM EDT
why did you stop smoking?
Question
05/22/20 1:58 PM EDT
It just wasn’t that fun anymore, plus it started to bother my asthma.
Do you vape?
Question
05/22/20 1:59 PM EDT
I’ve never vaped or smoked an e-cigarette. [AUDIO COMING SOON]
do you smoke the pot?
Question
05/22/20 1:59 PM EDT
Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.
At what age did you smoke?
Question
05/22/20 2:00 PM EDT
I started when I was about fifteen, and I stopped when I was twenty or twenty-one.
Do you drink alcohol?
Question
05/22/20 2:00 PM EDT
I do sometimes, yeah, when I go out with my friends.
How much alcohol do you take in a sitting? (Clarified to How much alcohol do you usually drink in one sitting?.)
Question
05/22/20 2:01 PM EDT
I never have more than two or three. If I go over that, I feel like hell the next day, so I stick to just a few. (Clarified to how much alcohol I drink in one sitting.)
How often do you drink?
Question
05/22/20 2:01 PM EDT
No more than once or twice a week, sometimes less.
Its good not to take a lot of alcohol and also to stop taking recreational drugs, they are addictive. (No matching questions found.)
Question
05/22/20 2:04 PM EDT
Its good not to take a lot of alcohol and also to stop taking recreational drugs, they are addictive.
Educate
05/22/20 2:04 PM EDT
Sure, I think I understand what you mean.
Do you take coffee?
Question
05/22/20 2:05 PM EDT
Never. I don’t like it. Too bitter for my taste.
Do you take carbonated sodas? (No matching questions found.)
Question
05/22/20 2:09 PM EDT
Do you take sodas? (No matching questions found.)
Question
05/22/20 2:10 PM EDT
Do you smoke the pot?
Question
05/22/20 2:10 PM EDT
Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.
Am happy that you stooped smoking pot, its not good for your health, especially asthma. (No matching questions found.)
Question
05/22/20 2:11 PM EDT
Am happy that you stooped smoking pot, its not good for your health, especially asthma.
Educate
05/22/20 2:11 PM EDT
Alright, thanks for letting me know.
Who do you love with? (Clarified to Who do you live with?.)
Question
05/22/20 2:12 PM EDT
Right now I live back at home with my mom and my sister. (Clarified to who I live with.)
Have you been abused?
Question
05/22/20 2:12 PM EDT
No, no way. I’ve never been hurt or anything in the way that you’re talking about.
Sorry for the discomforts
Empathize
05/22/20 2:27 PM EDT
Thanks for understanding.
Do you have a boyfriend?
Question
05/22/20 2:27 PM EDT
Um, not right now.
Have you had a boyfriend in the past?
Question
05/22/20 2:28 PM EDT
Um, not right now.
How many boyfriends you had? (Clarified to How many boyfriends have you had?.)
Question
05/22/20 2:28 PM EDT
Oh, gosh…I guess four or five. (Clarified to how many boyfriends I have had.)
Have you tested for HIV/AIDS?
Question
05/22/20 2:54 PM EDT
No. I don’t think I need one. I don’t know anybody with HIV or AIDS.
Have you tested for STDs? (Clarified to Have you been tested for STDs?.)
Question
05/22/20 2:54 PM EDT
Yeah, I’m sure they did those tests when I went for a pap smear before. (Clarified to if I have ever been tested for STDs.)
Have you been tested for STDs with your boyfriend? (Clarified to Has your friend been checked for sexually transmitted infections?.)
Question
05/22/20 2:55 PM EDT
When we were together, he told me he didn’t have any STDs, and I believed him. I don’t know if he was ever tested. (Clarified to if my sexual partner has been tested for STIs.)
It is good to be tested for STDs to be sure
Educate
05/22/20 2:56 PM EDT
Sure, I think I understand what you mean.
When were you tested for stds?
Question
05/22/20 2:56 PM EDT
I guess probably the last time I went for a pap smear…that was, um, maybe four years ago now.
Do you have any symptoms for STDs?
Question
05/22/20 2:57 PM EDT
No. I’ve never had any symptoms like that.
Any vaginal discharge?
Question
05/22/20 2:58 PM EDT
Um, I have hardly any discharge, and it’s, like, clear.
Have you had any muscle pain?
Question
05/22/20 2:59 PM EDT
No.
Any joint pain?
Question
05/22/20 3:00 PM EDT
No.
Joint swelling? (Clarified to Do you have any joint pain or swelling?.)
Question
05/22/20 3:00 PM EDT
Not really. (Clarified to if I have any joint pain or swelling.)
what about back pain?
Question
05/22/20 3:01 PM EDT
My back’s fine.
How are your eyes?
Question
05/22/20 3:01 PM EDT
I’ve actually been noticing problems lately. When I’m reading or studying I’ll notice that things start to get kind of blurry.
Do you wear eye glasses?
Question
05/22/20 3:02 PM EDT
I don’t wear glasses–or contacts.
Do you have any problem with moth or jaw? (Clarified to Do you have mouth or jaw problems?.)
Question
05/22/20 3:02 PM EDT
No, neither. (Clarified to if I have mouth or jaw problems.)
Have you had any dental problems?
Question
05/22/20 3:03 PM EDT
Nope, no problems.
Any change in sense of taste?
Question
05/22/20 3:04 PM EDT
No, I think my sense of taste is fine.
Do have a painful mouth?
Question
05/22/20 3:04 PM EDT
No.
Any difficulties swallowing?
Question
05/22/20 3:05 PM EDT
Nope.
Any sore throat?
Question
05/22/20 3:05 PM EDT
No, it’s fine.
Any swollen glands?
Question
05/22/20 3:05 PM EDT
No, not that I noticed.
Have you had a breast exam?
Question
05/22/20 3:05 PM EDT
I haven’t had a mammogram. I’ve just had the exam where the doctor felt around for lumps.
any pain in the breasts
Question
05/22/20 3:06 PM EDT
No. Maybe some soreness before my period, but that seems pretty typical.
any discharge from nipples?
Question
05/22/20 3:06 PM EDT
Uh, no, definitely not.
have you nosebleed?
Question
05/22/20 3:07 PM EDT
No.
Any chest pains?
Question
05/22/20 3:07 PM EDT
No, my chest feels tight when I have breathing problems, but it doesn’t hurt.
Any irregular heartbeat? (Clarified to Have you ever had an irregular heartbeat?.)
Question
05/22/20 3:08 PM EDT
I think my heart’s fine. I don’t really notice how it beats. (Clarified to if I have had an irregular heartbeat.)
do you have problems with your bowel problems? (Clarified to Do you have difficulty moving your bowels?.)
Question
05/22/20 3:09 PM EDT
No. No problems like that. (Clarified to if I have trouble moving my bowels.)
Have you noticed any changes with your skin?
Question
05/22/20 3:11 PM EDT
Well…I guess I was noticing the other day that the skin around my neck is looking weird. Like the skin is getting darker. And my skin’s breaking out, but that’s how it is.
What is your general heath condition?
Question
05/22/20 3:12 PM EDT
Generally? My foot has just been hurting from a scrape I got. [AUDIO COMING SOON]
Are you tired or fatigued?
Question
05/22/20 3:13 PM EDT
Most days I feel pretty exhausted by the end of the day…I’m tired now, too, but I think that’s just because I slept terribly.
How is your sleep pattern?
Question
05/22/20 3:13 PM EDT
I try to be in bed by eleven or midnight, and I get up at seven or eight.
Do eyes itch?
Question
05/22/20 3:14 PM EDT
No. That only happens around cats or dust.
Any hearing problem?
Question
05/22/20 3:14 PM EDT
No.
Any ear discharge?
Question
05/22/20 3:15 PM EDT
No.
does your mother have any health problem?
Question
05/22/20 3:17 PM EDT
Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
Does your father have medical problems?
Question
05/22/20 3:17 PM EDT
Well, he passed away. But he had a couple things . . . Type 2 diabetes, like me, and high cholesterol and blood pressure.
Am sorry to hear that.
Empathize
05/22/20 3:17 PM EDT
I appreciate you telling me that.
When did your farther pass away? (Clarified to When did your father pass away?.)
Question
05/22/20 3:17 PM EDT
It was last year… I guess a little over a year ago. (Clarified to when my dad died.)
How old was your father when he passed away?
Question
05/22/20 3:18 PM EDT
Last year when Dad passed, he was only 58.
How did you cope with your fathers death?
Question
05/22/20 3:18 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.
You are lucky you have a great support system that helped you cope easily.
Empathize
05/22/20 3:20 PM EDT
Thanks for saying that.
What was the cause of your fathers death?
Question
05/22/20 3:20 PM EDT
He died in a car accident.
Am sorry to hear that
Empathize
05/22/20 3:20 PM EDT
I appreciate you saying that.
No, I’m fine right now.
Measured wound: 2 cm x 1.5 cm, 2.5 mm deep
Exam Action
05/22/20 4:25 PM EDT
Swabbed wound and sent to lab for C & S
Exam Action
05/22/20 4:25 PM EDT
Cleansed and irrigated wound with normal saline and applied dry sterile dressing.
Exam Action
05/22/20 4:25 PM EDT
