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