Tina Jones HEENT Shadow Health Assessment Transcript

Tina Jones HEENT Shadow Health Assessment Transcript

 

Transcript

Started: May 17, 2020 | Total Time:96 min
Your avatar
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

Tina Jones
Hey.
Your avatar
May i know your name please?

Question
05/29/20 6:31 PM EDT

Tina Jones
Tina Jones.
Your avatar
What brings you the the Clinic today Tina?

Question
05/29/20 6:31 PM EDT

Tina Jones
My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
Your avatar
Am sorry to hear that

Empathize
05/29/20 6:32 PM EDT

Tina Jones
I appreciate you telling me that.
Your avatar
How long have you had these symptoms?

Question
05/29/20 6:32 PM EDT

Tina Jones
My itchy eyes, runny nose, and sore throat all started a week ago. [AUDIO COMING SOON]
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Have you ever had these symptoms before?

Question
05/29/20 6:33 PM EDT

Tina Jones
No.
Your avatar
How severe is your sore throat?

Question
05/29/20 6:36 PM EDT

Tina Jones
It’s not… terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won’t go away.
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Is the sore throat constant

Question
05/29/20 6:36 PM EDT

Tina Jones
Yeah, it’s sore pretty much all the time.
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can you describe the pain?

Question
05/29/20 6:38 PM EDT

Tina Jones
It’s really sore, and it itches a lot, like in the back.
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how would you rate te pain on a scale of 0 to 10 ?

Question
05/29/20 6:38 PM EDT

Tina Jones
It’s like a 4 out of 10, maybe.
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Does the pain radiate?

Question
05/29/20 6:38 PM EDT

Tina Jones
No, it’s just in my throat.
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What do you think is casing the sore throat?

Question
05/29/20 6:39 PM EDT

Tina Jones
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.
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Does anything make the throat feel better?

Question
05/29/20 6:40 PM EDT

Tina Jones
All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
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Does anything make the pain worse?

Question
05/29/20 6:41 PM EDT

Tina Jones
It’s a little worse in the morning, but that’s really the only pattern I’ve noticed.
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Do you have any other symptoms associated with the sore throat? (No matching questions found.)

Question
05/29/20 6:43 PM EDT

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do you have any nasal discharge?

Question
05/29/20 6:43 PM EDT

Tina Jones
Yes, it won’t stop running!
Your avatar

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Your avatar
Do you take any over the counter medications?

Question
05/29/20 6:50 PM EDT

Tina Jones
I’ve been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often.
Your avatar
How often do you get headaches?

Question
05/29/20 6:51 PM EDT

Tina Jones
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.
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How would you rate these headaches?

Question
05/29/20 6:51 PM EDT

Tina Jones
Not too bad. . . I’d say about 3. Or a 4 if I really push it.
Your avatar
What helps your headache?

Question
05/29/20 6:51 PM EDT

Tina Jones
I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON]
Your avatar
Does anything make your headache worse?

Question
05/29/20 6:52 PM EDT

Tina Jones
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.
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How long have you had these headaches?

Question
05/29/20 6:52 PM EDT

Tina Jones
I’m not sure — Maybe over the last year or so.
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Do you take any herbal supplements?

Question
05/29/20 6:53 PM EDT

Tina Jones
No, I don’t take anything herbal.
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Do you take any prescription medications?

Question
05/29/20 6:53 PM EDT

Tina Jones

WE GUARANTEE A DCE SCORE OF ABOVE 95% AND HANDLE THE SOAP NOTE

 

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Do you take vitamins?

Question
05/29/20 7:21 PM EDT

Tina Jones
No, I don’t take any vitamins.
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Are your immunizations up to date?

Question
05/29/20 7:22 PM EDT

Tina Jones
I’m pretty sure I am, yeah.
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What side effects did you have with metformin?

Question
05/29/20 7:23 PM EDT

Tina Jones
I felt sick and gassy all the time. It was really uncomfortable.
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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

Tina Jones
Alright, thanks for letting me know.
Your avatar
Are you allergic to medications?

Question
05/29/20 7:28 PM EDT

Tina Jones
Yeah, I’m allergic to penicillin.
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Do you have seasonal allergies?

Question
05/29/20 7:28 PM EDT

Tina Jones
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.
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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

Tina Jones
Nope, no food allergies that I know of. (Clarified to if I have food allergies.)
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Do you smoke cigarettes?

Question
05/29/20 7:32 PM EDT

Tina Jones
No, I’ve never smoked a cigarette in my life.
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Do you take alcohol? (No matching questions found.)

Question
05/29/20 7:32 PM EDT

Your avatar
Do you drink alcohol?

Question
05/29/20 7:33 PM EDT

Tina Jones
I do sometimes, yeah, when I go out with my friends.
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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

Tina Jones
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.)
Your avatar
Thats moderate drinking which is ok.

Educate
05/29/20 7:34 PM EDT

Tina Jones
Thanks for telling me.
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What type of alcohol do you take?

Question
05/29/20 7:34 PM EDT

Tina Jones
I usually get rum and diet Coke. I don’t know why that matters.
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Different drinks have different alcohol levels, thats why i asked.

Educate
05/29/20 7:35 PM EDT

Tina Jones
OK, I understand.
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How is your family medical history?

Question
05/29/20 7:35 PM EDT

Tina Jones
My mom has some issues, and I think some of my grandparents did, too.
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What health issues does your mother have?

Question
05/29/20 7:35 PM EDT

Tina Jones
Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
Your avatar
What medical issues does your father have? (Clarified to Tell me about your dad’s health?.)

Question
05/29/20 7:36 PM EDT

Tina Jones
He passed last year. (Clarified to what health issues my dad has.)
Your avatar
Am sorry to hear that

Empathize
05/29/20 7:36 PM EDT

Tina Jones
Thanks for understanding.
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did your father have any medical conditions?

Question
05/29/20 7:37 PM EDT

Tina Jones
He had high blood pressure and cholesterol, and diabetes too…the same kind as me.
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What health issues does your maternal grandmother have?

Question
05/29/20 7:37 PM EDT

Tina Jones
Nana had high blood pressure and cholesterol, I think.
Your avatar
What issues does you maternal grandfather have?

Question
05/29/20 7:38 PM EDT

Tina Jones
Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
Your avatar
What health issues does you paternal grand mother have?

Question
05/29/20 7:38 PM EDT

Tina Jones
Granny’s doing good. She’s still living on her own. She’s slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy.
Your avatar
What health issues does your paternal grandfather have?

Question
05/29/20 7:39 PM EDT

Tina Jones
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.
Your avatar
how did you cope with your fathers death?

Question
05/29/20 7:39 PM EDT

Tina Jones
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.
Your avatar
Seems you have a strong support system which is great.

Empathize
05/29/20 7:40 PM EDT

Tina Jones
Thanks.
Your avatar
What health conditions does your sister have?

Question
05/29/20 7:41 PM EDT

Tina Jones
She’s pretty healthy. She has asthma too, but she almost never has attacks.
Your avatar
what health conditions does your brother have?

Question
05/29/20 7:41 PM EDT

Tina Jones
None that I know of. He’s got some extra weight on him, I guess.
Your avatar
Anyone one with an obesity problem in your family?

Question
05/29/20 7:45 PM EDT

Tina Jones
No, I don’t think so. My brother and my dad are kind of big, but I wouldn’t say they were obese or anything.
Your avatar
Any one with alcoholism problem in the family?

Question
05/29/20 7:46 PM EDT

Tina Jones
One person in the family, my dad’s brother, has an alcohol problem, but we never see him.
Your avatar
What work do you do?

Question
05/29/20 7:47 PM EDT

Tina Jones
I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up.
Your avatar
Am happy to hear that your job is fine and you are doing well

Empathize
05/29/20 7:47 PM EDT

Tina Jones
Thanks for understanding.
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What is your highest level of education?

Question
05/29/20 7:48 PM EDT

Tina Jones
Well, I’m finishing up my Bachelor’s degree right now.
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What is your Major?

Question
05/29/20 7:48 PM EDT

Tina Jones
I’m going to get my bachelor’s in accounting.
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Tina Jones
I really haven’t travelled that much…I’ve always wanted to go to France but I’ve never even been out of the country. I’m always busy with work or school anyway though. We used to go on some family vacations when I was younger, but they were usually just to see some family in other states.
Your avatar
Am sure when you get less busy, you will travel more

Empathize
05/29/20 7:52 PM EDT

Tina Jones
I appreciate you saying that.
Your avatar
Have you been wheezing?

Question
05/29/20 7:52 PM EDT

Tina Jones
No, I haven’t been wheezing this week.
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Please let me examine you now. (No matching questions found.)

Question
05/29/20 7:53 PM EDT

Your avatar
Please let me examine you now.

Educate
05/29/20 7:53 PM EDT

Tina Jones
Sure, I think I understand what you mean.
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Inspected general face

Exam Action
05/29/20 7:57 PM EDT

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Inspected forehead and scalp

Exam Action
05/29/20 7:58 PM EDT

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Inspected nose and mouth

Exam Action
05/29/20 7:58 PM EDT

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Inspected left side of face

Exam Action
05/29/20 7:58 PM EDT

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Inspected back of head

Exam Action
05/29/20 7:58 PM EDT

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Inspected right side of face

Exam Action
05/29/20 7:58 PM EDT

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Inspected general face

Exam Action
05/29/20 7:58 PM EDT

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Inspected right side of face

Exam Action
05/29/20 7:58 PM EDT

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Inspected general face

Exam Action
05/29/20 7:58 PM EDT

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Inspected nose and mouth

Exam Action
05/29/20 7:58 PM EDT

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Inspected forehead and scalp

Exam Action
05/29/20 7:58 PM EDT

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Inspected nose and mouth

Exam Action
05/29/20 7:58 PM EDT

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Inspected right orbital area and sclera

Exam Action
05/29/20 7:59 PM EDT

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Inspected lower conjunctiva

Exam Action
05/29/20 7:59 PM EDT

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Inspected upper conjunctiva

Exam Action
05/29/20 8:00 PM EDT

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Inspected upper conjunctiva

Exam Action
05/29/20 8:00 PM EDT

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Inspected left orbital area and sclera

Exam Action
05/29/20 8:00 PM EDT

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Performed otoscopic examination of right naris

Exam Action
05/29/20 8:00 PM EDT

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Performed otoscopic examination of left naris

Exam Action
05/29/20 8:01 PM EDT

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Performed otoscopic examination of right ear

Exam Action
05/29/20 8:02 PM EDT

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Performed otoscopic examination of left ear

Exam Action
05/29/20 8:02 PM EDT

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Inspected mouth

Exam Action
05/29/20 8:03 PM EDT

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Inspected mouth: pushed tongue left with tongue blade

Exam Action
05/29/20 8:04 PM EDT

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Inspect mouth: pushed tongue right with tongue blade

Exam Action
05/29/20 8:04 PM EDT

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Inspect mouth: lifted tongue with tongue blade

Exam Action
05/29/20 8:04 PM EDT

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Inspected mouth: depressed tongue with tongue blade

Exam Action
05/29/20 8:04 PM EDT

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Inspected front of neck

Exam Action
05/29/20 8:06 PM EDT

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Inspected left side of neck

Exam Action
05/29/20 8:06 PM EDT

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Inspected back of neck

Exam Action
05/29/20 8:06 PM EDT

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Inspected right side of neck

Exam Action
05/29/20 8:06 PM EDT

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Inspected back of neck

Exam Action
05/29/20 8:06 PM EDT

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Inspected right side of neck

Exam Action
05/29/20 8:07 PM EDT

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Inspected front of neck

Exam Action
05/29/20 8:07 PM EDT

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Inspected right side of neck

Exam Action
05/29/20 8:07 PM EDT

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Inspected front of neck

Exam Action
05/29/20 8:07 PM EDT

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Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported

Exam Action
05/29/20 8:07 PM EDT

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Palpated maxillary sinuses: No tenderness reported

Exam Action
05/29/20 8:08 PM EDT

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Palpated frontal sinuses: No tenderness reported

Exam Action
05/29/20 8:08 PM EDT

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Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+

Exam Action
05/29/20 8:08 PM EDT

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Palpated right carotid artery: No thrill, 2+

Exam Action
05/29/20 8:10 PM EDT

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Palpated left carotid artery: No thrill, 2+

Exam Action
05/29/20 8:10 PM EDT

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Palpated jaw: Full range of motion, no popping or clicking

Exam Action
05/29/20 8:11 PM EDT

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Palpated axillary lymph nodes: Not palpable

Exam Action
05/29/20 8:11 PM EDT

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Palpated supraclavicular lymph nodes: Not palpable

Exam Action
05/29/20 8:12 PM EDT

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Palpated lymph nodes of head and neck: Not palpable

Exam Action
05/29/20 8:12 PM EDT

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Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported

Exam Action
05/29/20 8:12 PM EDT

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Auscultated breath sounds in anterior right lower lobe

Exam Action
05/29/20 8:13 PM EDT

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Auscultated breath sounds in anterior right middle lobe

Exam Action
05/29/20 8:13 PM EDT

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Auscultated breath sounds in anterior right upper lobe

Exam Action
05/29/20 8:13 PM EDT

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Auscultated breath sounds in anterior left upper lobe

Exam Action
05/29/20 8:13 PM EDT

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Auscultated breath sounds in anterior left mid-chest (upper lobe)

Exam Action
05/29/20 8:13 PM EDT

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Auscultated breath sounds in anterior left lower lobe

Exam Action
05/29/20 8:13 PM EDT

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Auscultated breath sounds in posterior left upper lobe

Exam Action
05/29/20 8:13 PM EDT

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Auscultated breath sounds in posterior left mid-back (lower lobe)

Exam Action
05/29/20 8:13 PM EDT

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Auscultated breath sounds in posterior left lower lobe

Exam Action
05/29/20 8:13 PM EDT

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Auscultated breath sounds in posterior left lower lobe on side

Exam Action
05/29/20 8:13 PM EDT

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Auscultated breath sounds in posterior left lower lobe near spine

Exam Action
05/29/20 8:13 PM EDT

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Auscultated breath sounds in posterior right lower lobe near spine

Exam Action
05/29/20 8:14 PM EDT

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Auscultated breath sounds in posterior right lower lobe on side

Exam Action
05/29/20 8:14 PM EDT

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Auscultated breath sounds in posterior right lower lobe

Exam Action
05/29/20 8:14 PM EDT

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Auscultated breath sounds in posterior right mid-back (lower lobe)

Exam Action
05/29/20 8:14 PM EDT

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Auscultated breath sounds in posterior right upper lobe

Exam Action
05/29/20 8:14 PM EDT

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Auscultated right temporal pulse

Exam Action
05/29/20 8:14 PM EDT

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Auscultated left temporal pulse

Exam Action
05/29/20 8:14 PM EDT

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Auscultated right carotid pulse

Exam Action
05/29/20 8:15 PM EDT

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Auscultated left carotid pulse

Exam Action
05/29/20 8:15 PM EDT

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Tested left pupillary reaction with penlight

Exam Action
05/29/20 8:16 PM EDT

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Tested right pupillary reaction with penlight

Exam Action
05/29/20 8:16 PM EDT

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Follow my finger with just your eyes

Question
05/29/20 8:17 PM EDT

Tina Jones
Ok.
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Tested EOM to the upper right

Exam Action
05/29/20 8:17 PM EDT

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Tested EOM to the lower right

Exam Action
05/29/20 8:17 PM EDT

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Tested EOM to the lower center

Exam Action
05/29/20 8:17 PM EDT

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Tested convergence to the center

Exam Action
05/29/20 8:17 PM EDT

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Tested EOM to the upper center

Exam Action
05/29/20 8:17 PM EDT

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Tested EOM to the upper left

Exam Action
05/29/20 8:17 PM EDT

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Tested EOM to the lower left

Exam Action
05/29/20 8:17 PM EDT

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Tell me when you can no loner see

Question
05/29/20 8:18 PM EDT

Tina Jones
Ok, I will.
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Tested peripheral vision

Exam Action
05/29/20 8:18 PM EDT

Tina Jones
Now.
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Examined fundus of right eye with ophthalmoscope

Exam Action
05/29/20 8:20 PM EDT

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Examined fundus of left eye with ophthalmoscope

Exam Action
05/29/20 8:21 PM EDT

Tina Jones
F P
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Is the volume the same in both ears or louder in one ear

Question
05/29/20 8:24 PM EDT

Tina Jones
Ok.
Tina Jones
Same in both ears.
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Performed Weber test with tuning fork

Exam Action
05/29/20 8:25 PM EDT

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Tell me when you no longer hear the ringing

Question
05/29/20 8:25 PM EDT

Tina Jones
Ok, I will.
Tina Jones
Now.
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F.

Question
05/29/20 8:26 PM EDT

Tina Jones
F.
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Eight

Question
05/29/20 8:26 PM EDT

Tina Jones
Eight.
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W.

Question
05/29/20 8:26 PM EDT

Tina Jones
W.
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Performed whisper test in right ear

Exam Action
05/29/20 8:26 PM EDT

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Four

Question
05/29/20 8:26 PM EDT

Tina Jones
Four.
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R.

Question
05/29/20 8:26 PM EDT

Tina Jones
R.
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Nine.

Question
05/29/20 8:26 PM EDT

Tina Jones
Nine.
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Performed whisper test in left ear

Exam Action
05/29/20 8:27 PM EDT

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Tested gag reflex with tongue blade

Exam Action
05/29/20 8:27 PM EDT

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