TINA JONES HEALTH HISTORY SHADOW HEALTH TRANSCRIPT

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TINA JONES HEALTH HISTORY SHADOW HEALTH TRANSCRIPT

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!

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