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TINA JONES HEENT SHADOW HEALTH ASSESSMENT TRANSCRIPT
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
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