Tina Jones Health History shadow health transcript
Hello, I am xxxxx. I will be interviewing you and later perform a physical examination
Greet
Tina Jones Health History shadow health transcript
Hey.
What is your name?
Question
03/21/21 8:33 AM EDT
Tina Jones.
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What brought you here today?
Question
03/21/21 8:33 AM 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
03/21/21 8:34 AM EDT
Thanks for saying that.
When did you get the scrape?
Question
03/21/21 8:34 AM EDT
Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
Sorry Ms. Tina
Empathize
03/21/21 8:35 AM EDT
I appreciate you telling me that.
How severe is the pain?
Question
03/21/21 8:35 AM EDT
It’s really bad.
Sorry about the pain
Empathize
03/21/21 8:35 AM EDT
Thanks for understanding.
How would you rate the pain in a scale of 10? (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)
Question
03/21/21 8:36 AM 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.)
Does the pain radiate?
Question
03/21/21 8:36 AM EDT
The pain’s worse in my foot, but I feel it moving up into my ankle, too.
Ohh, sorry about that.
Empathize
03/21/21 8:36 AM EDT
Thanks.
Can you describe the pain?
Question
03/21/21 8:37 AM EDT
It’s throbbing and like, sharp if I try to put weight on it.
Did you hurt any other part? (Clarified to Do you have any other injuries?.)
Question
03/21/21 8:38 AM EDT
No, I caught myself on the railing so I didn’t fall on the ground. Only my foot got hurt. (Clarified to if I have other injuries.)
how has the pain changed over time?
Question
03/21/21 8:38 AM 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.
How painful is the ankle? (Clarified to How is your foot getting worse?.)
Question
03/21/21 8:38 AM EDT
It just hurts more and is kind of throbbing now. (Clarified to how the foot pain is getting worse.)
Is it possible to stand on your foot? (Clarified to Can you manage to stand on your right foot?.)
Question
03/21/21 8:39 AM EDT
No, I can’t put weight on my foot without really sharp pain. (Clarified to if I can stand on my right foot.)
Sorry abiout that
Empathize
03/21/21 8:39 AM EDT
I appreciate you saying that.
Where is the location of the pain?
Question
03/21/21 8:40 AM 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
03/21/21 8:40 AM EDT
My right foot.
Were you wearing shoes?
Question
03/21/21 8:40 AM EDT
No, I was barefoot.
Did you have alcohol before the injury?
Question
03/21/21 8:41 AM EDT
No, I was stone-cold sober. It was the middle of the day.
did you use home remedies on your foot?
Question
03/21/21 8:42 AM EDT
Yeah, I made sure to clean it and keep it bandaged.
what did you use to clean it?
Question
03/21/21 8:42 AM EDT
Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off.
when did you go to the ER?
Question
03/21/21 8:42 AM EDT
I went about an hour after I fell, I think.
dID YOU GET MEDICATION AT THE ER?
Question
03/21/21 8:43 AM EDT
Yes, they wrote me a prescription for some pain pills.
What is the name of the pain medication?
Question
03/21/21 8:43 AM EDT
It’s called tramadol.
what dosage of tramadol?
Question
03/21/21 8:43 AM EDT
I’m not 100% sure, but I think they’re 50 milligrams.
How often were you taking tramadol?
Question
03/21/21 8:44 AM EDT
I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
Did tramadol relieve pain?
Question
03/21/21 8:45 AM EDT
I’ve only been taking the pain pills the ER gave me and staying off it. . . and keeping the wound clean.
Has your foot bled since the injury?
Question
03/21/21 8:45 AM EDT
It’s not bleeding anymore. It only bled right after I scraped it.
Good to hear that
Empathize
03/21/21 8:46 AM EDT
Thanks for saying that.
What happened after you scrapped the foot?
Question
03/21/21 8:46 AM EDT
I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
It is good to seek medical attention
Educate
03/21/21 8:47 AM EDT
Alright, thanks for letting me know.
how effective is the pain medication?
Question
03/21/21 8:47 AM EDT
They only help for a few hours at a time.
am sorry to hear that
Empathize
03/21/21 8:47 AM EDT
I appreciate you saying that.
how have you cared for the scrape?
Question
03/21/21 8:48 AM EDT
I made sure to clean it and just keep it bandaged. And I put Neosporin on it.
good to hear
Empathize
03/21/21 8:48 AM EDT
I appreciate you telling me that.
What happens after applying neosporin?
Question
03/21/21 8:48 AM EDT
I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
how effective was the neosporin?
Question
03/21/21 8:49 AM EDT
Well, I had to come back to get my foot checked out even though I used the ointment. [AUDIO COMING SOON]
how often have you been cleaning the scrape?
Question
03/21/21 8:49 AM EDT
Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off.
its good to keep it clean
Educate
03/21/21 8:49 AM EDT
Thanks for telling me.
Is the wound swollen
Question
03/21/21 8:50 AM EDT
Yeah, it looks swollen around the scrape.
does your scrape have odor?
Question
03/21/21 8:50 AM EDT
Um, no, not that I know of… That sounds gross.
does the scrape have pus?
Question
03/21/21 8:51 AM EDT
Yeah, there’s definitely pus.
what is the color of the pus?
Question
03/21/21 8:52 AM EDT
It’s… white or maybe off-white.
any temperature change around the scrape?
Question
03/21/21 8:52 AM EDT
No.
are you having trouble getting around?
Question
03/21/21 8:53 AM EDT
Yes! I mean, I literally can’t put weight on my foot, the pain is so sharp.
sorry to hear that
Empathize
03/21/21 8:53 AM EDT
Thanks for understanding.
who has been helping you since you hurt your foot?
Question
03/21/21 8:53 AM EDT
I’m lucky living at home because my mom is around to help me, and my sister too.
that is great
Empathize
03/21/21 8:55 AM EDT
Thanks.
Do you work?
Question
03/21/21 8:55 AM 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.
Has the injury prevented you from going to work?
Question
03/21/21 8:55 AM EDT
Well, I tried to go in two days ago but I couldn’t walk well enough, so I just went home after a couple hours. And I didn’t go in yesterday. My boss was understanding, but I need to be able to work!
seem you really love your work
Empathize
03/21/21 8:56 AM EDT
Thanks for saying that.
Do you have other health problems?
Question
03/21/21 8:56 AM EDT
Um, the only things I know I’m diagnosed with are diabetes. And asthma.
when were you diagnosed with asthma?
Question
03/21/21 8:56 AM 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.
sorry about that
Empathize
03/21/21 8:57 AM EDT
Thanks.
when was your last asthma attack?
Question
03/21/21 8:57 AM 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.
how was your asthma in high school? (No matching questions found.)
Question
03/21/21 8:58 AM EDT
what happens when you have an asthma attack?
Question
03/21/21 8:59 AM 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.
sorry about that Ms. Tina
Empathize
03/21/21 9:00 AM EDT
I appreciate you saying that.
do you get tight chest?
Question
03/21/21 9:02 AM EDT
Well. . . when my asthma gets bad my chest feels pretty tight, like I can’t take in air.
sorry about that
Empathize
03/21/21 9:02 AM EDT
I appreciate you telling me that.
Do you have breathing difficulties? (Clarified to Do you have breathing problems?.)
Question
03/21/21 10:13 AM EDT
Well, my breathing’s been fine the last few days. But I do get short of breath sometimes, because of my asthma. (Clarified to if I have breathing problems.)
how is your wheezing?
Question
Tina Jones Health History shadow health transcript
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.
I understand. probably an allergy triggered the breathing problems
Educate
03/21/21 10:14 AM EDT
OK, I understand.
what do you use for your asthma?
Question
03/21/21 10:15 AM EDT
It’s just a regular Proventil inhaler.
how many times do you use the inhaler?
Question
03/21/21 10:15 AM 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.
what dose of proventil?
Question
03/21/21 10:16 AM EDT
I usually use two puffs from my albuterol inhaler — it’s 90 micgrograms a spray — but lately sometimes I need three puffs. [AUDIO COMING SOON]
always adhere to the prescribed dose
Educate
03/21/21 10:16 AM EDT
Sure, I think I understand what you mean.
have you been hospitalized because of asthma?
Question
03/21/21 10:17 AM EDT
I went a bunch of times when I was little, for asthma attacks. Tina Jones Health History shadow health transcript
Sorry about that
Empathize
03/21/21 10:27 AM EDT
Thanks for understanding.
what triggers your asthma attacks?
Question
03/21/21 10:28 AM 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. Tina Jones Health History shadow health transcript
what happens when you are around cats?
Question
03/21/21 10:28 AM 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?
Question
03/21/21 10:28 AM EDT
Nope.
do you have food allergies?
Question
03/21/21 10:28 AM EDT
Nope, no food allergies that I know of. Tina Jones Health History shadow health transcript
Do you have medication allergy?
Question
03/21/21 10:29 AM EDT
Yeah, I’m allergic to penicillin.
are you allergic to dust?
Question
03/21/21 10:29 AM EDT
Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust. Tina Jones Health History shadow health transcript
are you allergic to pollen?
Question
03/21/21 10:29 AM EDT
Not that I’ve noticed.
are you allergic to mould? (Clarified to Are you allergic to bee stings?.)
Question
03/21/21 10:30 AM EDT
No, not that I know of. (Clarified to if I am allergic to bee stings.)
It is good to stay away from allergens
Educate
03/21/21 10:30 AM EDT
That makes sense.
what type of reaction do you have to penicillin?
Question
03/21/21 10:31 AM 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. Tina Jones Health History shadow health transcript
what reaction do you have to dust?
Question
03/21/21 10:31 AM EDT
If I’m around a lot of dust, I can get sneezy, or I can start wheezing. Sometimes I get itchy eyes.
what other allergies do you have? Tina Jones Health History shadow health transcript
Question
03/21/21 10:31 AM EDT
Well, besides cats, I’m allergic to penicillin.
when were you diagnosed with diabetes?
Question
03/21/21 10:32 AM EDT
I was diagnosed when I was 24. Tina Jones Health History shadow health transcript
how do you treat diabetes?
Question
03/21/21 10:32 AM EDT
I just watch what I eat and try to stay away from sweets.
what type of diabetes do you have?
Question
03/21/21 10:33 AM EDT
It’s type 2.
what medication do you take for diabetes?
Question
03/21/21 10:33 AM EDT
I don’t take medicine for it anymore.
why did you stop taking diabetes medication?
Question
03/21/21 10:33 AM EDT
I just got sick of dealing with it!
it is not advisable to stop taking medication without consulting your physician
Educate
03/21/21 10:37 AM EDT
Alright, thanks for letting me know. Tina Jones Health History shadow health transcript
what diabetes medication were you taking?
Question
03/21/21 10:37 AM EDT
It was Metformin.
what dose of metformin?
Question
03/21/21 10:38 AM EDT
Honestly, I don’t remember what the dose was when I was taking it.
Did you have issues affording the metformin?
Question
03/21/21 10:38 AM 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] Tina Jones Health History shadow health transcript
And it is good to know the prescribed dose
Educate
03/21/21 10:39 AM EDT
That makes sense.
how many times were you taking metformin?
Question
03/21/21 10:39 AM EDT
I think it was one pill, twice a day.
when did you stop taking metformin?
Question
03/21/21 10:39 AM EDT
About three years ago, honestly.
when did you start taking the metformin?
Question
03/21/21 10:40 AM EDT
When I was 24, right after I was first diagnosed.
how old are you now? Tina Jones Health History shadow health transcript
Question
03/21/21 10:40 AM EDT
I’m 28.
how do you mange your diabetes now?
Question
03/21/21 10:40 AM EDT
I just watch what I eat and try to stay away from sweets.
Great. diet plays a big role in managing diabetes
Educate
03/21/21 10:41 AM EDT
OK, I understand.
Describe your diet
Question
03/21/21 10:41 AM EDT
It’s pretty good, I think. I’m not a huge health nut or anything.
what did you have for dinner?
Question
03/21/21 10:41 AM EDT
Mom made baked chicken and mashed potatoes.
what did you have for lunch?
Question
03/21/21 10:42 AM EDT
I haven’t had lunch yet, it’s still the morning!
what is your typical dinner?
Question
03/21/21 10:42 AM EDT
The usual stuff. . . meatloaf, chicken, casseroles, pasta. . . stuff like that.
what is your typical breakfast?
Question
03/21/21 10:42 AM EDT
I’ll usually have a muffin or pumpkin bread from the cafe near my house.
It is good to have high intake of fruits and vegetables and avoid high caloris foods. Tina Jones Health History shadow health transcript.
Educate
03/21/21 10:45 AM EDT
Thanks for telling me.
Do you check your sugars?
Question
03/21/21 10:46 AM EDT
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.
how often do you check your sugar levels?
Question
03/21/21 10:47 AM EDT
I don’t check it very often, honestly. . . I think the last time was about a month ago.
it is important to regularly monitor your sugar levels
Educate
03/21/21 10:47 AM EDT
Sure, I think I understand what you mean.
Do you take sodas? (Clarified to Are you currently on the pill?.)
Question
03/21/21 10:47 AM EDT
I used to take it when I was with my last boyfriend, but I don’t use it anymore. (Clarified to if I am on the pill.)
do you know how to use a monitor?
Tina Jones Health History shadow health transcript
Yeah, the doctor showed me how.
do you feel thrifty often?
Question
03/21/21 10:49 AM EDT
Not so great… My foot really hurts right now.
do you take a lot of water? (Clarified to Do you drink a lot of water?.)
Question
03/21/21 10:49 AM EDT
Yeah, I’ve been drinking tons of water lately. (Clarified to if I drink a lot of water.)
are you very thirsty? (Clarified to Do you get excessive thirst?.)
Question
03/21/21 10:49 AM EDT
You know, I did notice lately that I’ve been really thirsty. (Clarified to if I have been really thirsty lately.)
Do you have frequent urination?
Question
03/21/21 10:50 AM EDT
Yeah, but I’ve been drinking more water. Tina Jones Health History shadow health transcript
how many times do you urinate?
Question
03/21/21 10:50 AM EDT
I don’t know. Every hour or two when I’m awake?
does your urine seem different?
Question
03/21/21 10:51 AM EDT
I’ve been noticing I’ve been having to pee a lot more recently, but I think that’s just because I’m drinking more water than normal.
how many times do you urinate at night?
Question
03/21/21 10:51 AM EDT
I probably have to get up two or three times a night.
do you sweat at night?
Question
03/21/21 10:51 AM EDT
I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets.
high water intake and excessive thrist may indicate diabetes. have your sugar levels checked
Educate
03/21/21 10:52 AM EDT
That makes sense.
how is your appetite?
Question
03/21/21 10:52 AM EDT
My appetite’s been huge lately. . . I feel like I’m hungry all the time.
Any weight changes?
Question
03/21/21 10:52 AM EDT
Yeah, I’ve lost some weight recently.
what triggered weight loss?
Question
03/21/21 10:52 AM EDT
I don’t know what caused it, I just lost weight.
It is good to have your physical health checked
Educate
03/21/21 10:53 AM EDT
Thanks for telling me. Tina Jones Health History shadow health transcript
Do you have hypertension?
Question
03/21/21 10:53 AM EDT
No, I’ve never been diagnosed with blood pressure problems.
do you check your blood pressure regularly?
Question
03/21/21 10:54 AM 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
03/21/21 10:54 AM 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 normal reading is 120/80. Yours is on hgiehr side and you need it monitored
Educate
03/21/21 10:54 AM EDT
Alright, thanks for letting me know.
