|
Hello, my name is SIMON. I will be conducting an interview and later perform a physical exam.
|
Greet Need Help Writing an Essay? Tell us about your assignment and we will find the best writer for your paper. Write My Essay For Me | |
|
Hey.
| ||
|
What is your name?
|
Question | |
|
Tina Jones.
| ||
|
Your date of birth?
|
Question | |
|
February 17th.
| ||
|
How old are you?
|
Question | |
|
I’m 28.
| ||
|
What brought you to the clinic today?
|
Question | |
|
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 | |
|
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 | |
|
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 | |
|
Thanks.
| ||
|
When was your last physical exam?
|
Question | |
|
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 | |
|
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 | |
|
I take it every morning, with breakfast.
| ||
|
What is the name of the birth control pill you took?
|
Question | |
|
They’re called Yaz.
| ||
|
Has your menstrual cycle improved since taking Yaz?
|
Question | |
|
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 | |
|
Thanks.
| ||
|
How long have you had asthma.
|
Question | |
|
I’ve had asthma a long time. . . since I was really little.
| ||
|
What age were you diagnosed with asthma?
|
Question | |
|
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 | |
|
Thanks.
| ||
|
How do you manage your asthma?
|
Question | |
|
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 | |
|
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 | |
|
Thanks for telling me.
| ||
|
What happens when you are around dust?
|
Question | |
|
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 | |
|
The daily inhaler is Flovent, and the rescue inhaler is Proventil.
| ||
|
How often do you use flovent?
|
Question | |
|
Twice a day.
| ||
|
When did you most recently use the flovent inhaler?
|
Question | |
|
I use my Flovent inhaler two times a day.
| ||
|
When did you last use your inhaler?
|
Question | |
|
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 |
|
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 | |
|
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 | |
|
Thanks.
| ||
|
Are you involved in church?
|
Question | |
|
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 | |
|
I’m actually feeling really good lately. . . not stressed at all.
| ||
|
How do you cope with stress?
|
Question | |
|
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 | |
|
Thanks.
| ||
|
Are you feeling depressed?
|
Question | |
|
No, I’m actually feeling really good these days.
| ||
|
How do you feel about your life?
|
Question | |
|
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 | |
|
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 | |
|
I’m sleeping a lot better now, which is a relief.
| ||
|
Good to hear.
|
Empathize | |
|
Thanks.
| ||
|
How many hours are you sleeping a night?
|
Question | |
|
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 | |
|
Thanks.
| ||
|
Have you ever smoked tobacco?
|
Question | |
|
No. I think it’s gross.
| ||
|
Have you ever used cocaine?
|
Question | |
|
No way, I have no interest in that. That stuff can mess you up.
| ||
|
Have you ever used heroin?
|
Question | |
|
Uh, no.
| ||
|
Have you ever used illegal drugs?
|
Question | |
|
Well, I used to smoke pot. . . but I don’t do that anymore.
| ||
|
What was the last time you smoked pot?
|
Question | |
|
I haven’t smoked pot since I was twenty or twenty-one.
| ||
|
Do you have any family history of mental illness?
|
Question | |
|
No. They’re crazy, but nobody’s diagnosed with anything.
| ||
|
Have you had suicidal thoughts?
|
Question | |
|
No, I’ve never done that.
| ||
|
Any new family medical history report?
|
Question | |
|
My mom has some issues, and I think some of my grandparents did, too.
| ||
|
How old is your mom?
|
Question | |
|
Mom is 50.
| ||
|
What medical problems does your mum have?
|
Question | |
|
Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
| ||
|
What medical problems did your father have?
|
Question | |
|
He had high blood pressure and cholesterol, and diabetes too…the same kind as me.
| ||
|
How old is your brother?
|
Question | |
|
He’s almost 27.
| ||
|
Does he have any medical issue? (Clarified to Does your younger sister have health problems?.)
|
Question | |
|
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 | |
|
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 | |
|
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 | |
|
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 | |
|
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 | |
|
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 | |
|
No. . . the last time I was sick was when I was having those heartburn problems a while ago.
| ||
|
Any fever?
|
Question | |
|
I haven’t had a fever.
| ||
|
Any chills?
|
Question | |
|
Nope, no chills.
| ||
|
Any acne?
|
Question | |
|
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 | |
|
I think I have a little less body hair than I used to.
| ||
|
Do your eyes feel itchy?
|
Question | |
|
They haven’t been itchy lately at all.
| ||
|
Are you having any redness in your eyes?
|
Question | |
|
My eyes haven’t been red lately. . . not since I came in with those allergies a while ago.
| ||
|
Are your eyes dry?
|
Question | |
|
My eyes don’t feel dry.
| ||
|
Do you have any pain in your eyes?
|
Question | |
|
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 | |
|
My ears feel fine.
| ||
|
Any changes in your hearing?
|
Question | |
|
My hearing is good.
| ||
|
Any ear pain?
|
Question | |
|
My ears feel fine.
| ||
|
Ear drainage? (Clarified to Do you have drainage from your ears?.)
|
Question | |
|
Nothing is coming out of my ears. (Clarified to if I have ear drainage.)
| ||
|
Any changes in your sense of smell?
|
Question | |
|
No.
| ||
|
Does any nose bleed?
|
Question | |
|
Nope, my nose isn’t bleeding at all.
| ||
|
Any sinus pressure?
|
Question | |
|
My sinuses have been fine.
| ||
|
Has your sense of taste changed?
|
Question | |
|
No, I think my sense of taste is fine.
| ||
|
Are you having dry mouth?
|
Question | |
|
My mouth hasn’t been dry.
| ||
|
ANY pain in your mouth?
|
Question | |
|
No, my mouth feels fine.
| ||
|
ANY sore throat?
|
Question | |
|
No, it’s fine.
| ||
|
Any issue with your gums?
|
Question | |
|
My gums have been fine.
| ||
|
Any issue with your tongue?
|
Question | |
|
My tongue feels fine.
| ||
|
Any difficulties when swallowing?
|
Question | |
|
I can swallow fine.
| ||
|
SORE throat?
|
Question | |
|
No, it’s fine.
| ||
|
Any voice changes?
|
Question | |
|
My voice has been fine.
| ||
|
Any swollen lymph nodes?
|
Question | |
|
My lymph nodes seem fine.
| ||
|
Are you having any nausea?
|
Question | |
|
No, I haven’t been nauseous at all.
| ||
|
Any vomiting?
|
Question | |
|
No.
| ||
|
ANY pain in the abdomen?
|
Question | |
|
I haven’t really had any stomach problems since I came in with them a while ago.
| ||
|
Any constipation?
|
Question | |
|
I don’t have that problem.
| ||
|
Any diarrhea?
|
Question | |
|
I haven’t had any problems with diarrhea.
| ||
|
Excessive flatulence?
|
Question | |
|
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 | |
|
Thanks for telling me.
| ||
|
Any food intolerance
|
Question | |
|
I can eat just about anything.
| ||
|
Any burning sensation when you urinate?
|
Question | |
|
No, it doesn’t burn when I pee.
| ||
|
Any blood in your urine?
|
Question | |
|
No! That doesn’t sound like it would be good.
| ||
|
Are you having any pain right now?
|
Question | |
|
I don’t have any pain anywhere.
| ||
|
Any vaginal discharge?
|
Question | |
|
My discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish.
| ||
|
Any vaginal itching?
|
Question | |
|
No, it feels normal.
| ||
|
Do you have any problem with your breasts?
|
Question | |
|
No, my breasts feel fine.
| ||
|
Any pain in the breasts?
|
Question | |
|
No, my breasts feel fine.
| ||
|
Are you having any dizziness/
|
Question | |
|
I haven’t been getting dizzy at all.
| ||
|
Any lightheadedness?
|
Question | |
|
No, I don’t really get lightheaded.
| ||
|
Any tingling?
|
Question | |
|
Nope, no tingling.
| ||
|
Any loss of balance?
|
Question | |
|
My balance is fine.
| ||
|
Any changes in sensation?
|
Question | |
|
I haven’t noticed any changes.
| ||
|
Any seizures?
|
Question | |
|
No, I’ve still never had problems with seizures, fortunately.
| ||
|
Do you have memory problems?
|
Question | |
|
I think my memory has been fine.
| ||
|
Any muscle pain?
|
Question | |
|
My muscles have felt great, especially since I started exercising more.
| ||
|
Joint pain?
|
Question | |
|
My joints always seem fine.
| ||
|
Any muscle weakness?
|
Question | |
|
No, I haven’t felt weak at all.
| ||
|
Any swelling?
|
Question | |
|
Nothing is swollen.
| ||
|
Performed pulse oximetry
|
Exam Action | |
|
Performed spirometry
|
Exam Action | |
|
Inspected scalp
|
Exam Action | |
|
Inspected scalp
|
Exam Action | |
|
Inspected hair on scalp
|
Exam Action | |
|
Inspected scalp
|
Exam Action | |
|
Inspected right eyebrow and orbital area
|
Exam Action | |
|
Inspected left eyebrow and orbital area
|
Exam Action | |
|
Inspected mouth: Oral mucosa moist. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
|
Exam Action |
Get Fast Writing Help – No Plagiarism Guarantee!
WRITE MY ESSAYGet Fast Writing Help – No Plagiarism Guarantee. Need help with your writing? Look no further. Our team of professional writers are ready to assist you with any writing needs. With a no plagiarism guarantee, you can be sure that your work will be original and plagiarism-free. Get fast and reliable writing help today!
Top-Rated Essay Writing Service | Flawless papers for All Your classes!
