HEENT Tina Jones Shadow Health Transcript

HEENT Tina Jones Shadow Health Transcript

All Lines (193)Interview Questions (102)Statements (15)Exam Actions (76)
Hello. My name is xxxx and I will talk with you today and later do a physical exam.
06/28/20 1:17 AM EDT
Hey.
What is your name?
06/28/20 1:17 AM EDT
Tina Jones.
What brings you here today?
06/28/20 1:30 AM EDT
My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are bothering me a lot.
I’m sorry to hear that.
06/28/20 1:31 AM EDT
Thanks for understanding.
How long have you had these symptoms?
06/28/20 1:32 AM EDT
My itchy eyes, runny nose, and sore throat all started a week ago. [AUDIO COMING SOON]
Have you ever had these symptoms before?
06/28/20 1:35 AM EDT
No.
How severe is your sore throat?
06/28/20 1:36 AM 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?
06/28/20 1:37 AM EDT
Yeah, it’s sore pretty much all the time.
Can you describe the pain?
06/28/20 1:42 AM EDT
It’s really sore, and it itches a lot, like in the back.
How would you rate the pain on a scale of 0 to 10?
06/28/20 1:43 AM EDT
It’s like a 4 out of 10, maybe.
Does the pain radiate?
06/28/20 1:44 AM EDT
No, it’s just in my throat.
What do you think is causing the sore throat?
06/28/20 1:45 AM 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 pain worse?
06/28/20 1:46 AM EDT
It’s a little worse in the morning, but that’s really the only pattern I’ve noticed.
Any other symptoms?
06/28/20 1:46 AM EDT
Let’s see… I have a lot going on so here’s the laundry list: sore and itchy throat, runny nose, itchy eyes.
Any nasal discharge? (Clarified to Has your nose been running?.)
06/28/20 1:47 AM EDT
Just when I’m around a cat. (Clarified to if my nose has been runny.)
Can you describe the nasal discharge?
06/28/20 1:48 AM EDT
I have a really runny nose. Everything coming out of it is really drippy and clear. It’s gross. [AUDIO COMING SOON]
Any eye problems?
06/28/20 1:52 AM EDT
You mean, other than this itchy-eye stuff going on right now? I guess… my eyes get blurry sometimes when I read. It seems like my vision is getting worse over the years.
Any shortness of breath? (Clarified to Do you currently have shortness of breath?.)
06/28/20 2:00 AM EDT
No, my breathing has been fine. (Clarified to if I have shortness of breath right now.)
Any other health problems?
06/28/20 2:05 AM EDT
I have diabetes and asthma, but I can’t even deal with those today.
When were you diagnosed with asthma?
06/28/20 2:06 AM EDT
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.
Have you been hospitalized for asthma?
06/28/20 2:08 AM EDT
I went a bunch of times when I was little, for asthma attacks.
When was the last time you were hospitalized for asthma?
06/28/20 2:09 AM EDT
I used to go to the hospital a lot, for asthma attacks, but not since I was sixteen.
Do you take any medication for asthma?
06/28/20 2:10 AM EDT
I just use my inhaler.
What is the name of the inhaler?
06/28/20 2:11 AM EDT
It’s just a regular Proventil inhaler.
How often do you use the inhaler?
06/28/20 2:11 AM EDT
I don’t use it every day — maybe I use it 2 or 3 times a week. Sometimes not at all.
How often do you get a runny nose?
06/28/20 2:18 AM EDT
It runs all day.
Have you been recently exposed to allergens?
06/28/20 2:20 AM EDT
Not lately.
Any allergies?
06/28/20 2:21 AM EDT
Yeah. I’m allergic to cats. And dust, too.
Are you allergic to pollen?
06/28/20 2:21 AM 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.
Are you allergic to mold?
06/28/20 2:22 AM EDT
Not that I know of.
Any family history of throat problems?
06/28/20 2:31 AM EDT
No.
Do you take over the counter medications?
06/28/20 2:31 AM 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?
06/28/20 2:32 AM 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?
06/28/20 2:33 AM EDT
Not too bad. . . I’d say about 3. Or a 4 if I really push it.
What helps your headache?
06/28/20 2:33 AM EDT
I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON]
Does anything make your headache worse?
06/28/20 2:

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Hello. My name is xxxx and I will interview you today and later do a physical exam. Greet
06/28/20 1:17 AM EDT
Hey.
What is your name? Question
06/28/20 1:17 AM EDT
Tina Jones.
What brings you here today? Question
06/28/20 1:30 AM 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
06/28/20 1:31 AM EDT
Thanks for understanding.
How long have you had these symptoms? Question
06/28/20 1:32 AM 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
06/28/20 1:35 AM EDT
No.
How severe is your sore throat? Question
06/28/20 1:36 AM 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
06/28/20 1:37 AM EDT
Yeah, it’s sore pretty much all the time.
Can you describe the pain? Question
06/28/20 1:42 AM EDT
It’s really sore, and it itches a lot, like in the back.
How would you rate the pain on a scale of 0 to 10? Question
06/28/20 1:43 AM EDT
It’s like a 4 out of 10, maybe.
Does the pain radiate? Question
06/28/20 1:44 AM EDT
No, it’s just in my throat.
What do you think is causing the sore throat? Question
06/28/20 1:45 AM 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 pain worse? Question
06/28/20 1:46 AM EDT
It’s a little worse in the morning, but that’s really the only pattern I’ve noticed.
Any other symptoms? Question
06/28/20 1:46 AM EDT
Let’s see… I have a lot going on so here’s the laundry list: sore and itchy throat, runny nose, itchy eyes.
Any nasal discharge? (Clarified to Has your nose been running?.) Question
06/28/20 1:47 AM EDT
Just when I’m around a cat. (Clarified to if my nose has been runny.)
Can you describe the nasal discharge? Question
06/28/20 1:48 AM EDT
I have a really runny nose. Everything coming out of it is really drippy and clear. It’s gross. [AUDIO COMING SOON]
Any eye problems? Question
06/28/20 1:52 AM EDT
You mean, other than this itchy-eye stuff going on right now? I guess… my eyes get blurry sometimes when I read. It seems like my vision is getting worse over the years.
Any shortness of breath? (Clarified to Do you currently have shortness of breath?.) Question
06/28/20 2:00 AM EDT
No, my breathing has been fine. (Clarified to if I have shortness of breath right now.)
Any other health problems? Question
06/28/20 2:05 AM EDT
I have diabetes and asthma, but I can’t even deal with those today.
When were you diagnosed with asthma? Question
06/28/20 2:06 AM EDT
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.
Have you been hospitalized for asthma? Question
06/28/20 2:08 AM EDT
I went a bunch of times when I was little, for asthma attacks.
When was the last time you were hospitalized for asthma? Question
06/28/20 2:09 AM EDT
I used to go to the hospital a lot, for asthma attacks, but not since I was sixteen.
Do you take any medication for asthma? Question
06/28/20 2:10 AM EDT
I just use my inhaler.
What is the name of the inhaler? Question
06/28/20 2:11 AM EDT
It’s just a regular Proventil inhaler.
How often do you use the inhaler? Question
06/28/20 2:11 AM EDT
I don’t use it every day — maybe I use it 2 or 3 times a week. Sometimes not at all.
How often do you get a runny nose? Question
06/28/20 2:18 AM EDT
It runs all day.
Have you been recently exposed to allergens? Question
06/28/20 2:20 AM EDT
Not lately.
Any allergies? Question
06/28/20 2:21 AM EDT
Yeah. I’m allergic to cats. And dust, too.
Are you allergic to pollen? Question
06/28/20 2:21 AM 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.
Are you allergic to mold? Question
06/28/20 2:22 AM EDT
Not that I know of.
Any family history of throat problems? Question
06/28/20 2:31 AM EDT
No.
Do you take over the counter medications? Question
06/28/20 2:31 AM 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
06/28/20 2:32 AM 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
06/28/20 2:33 AM EDT
Not too bad. . . I’d say about 3. Or a 4 if I really push it.
What helps your headache? Question
06/28/20 2:33 AM EDT
I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON]
Does anything make your headache worse? Question
06/28/20 2:35 AM 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
06/28/20 3:06 AM EDT
I’m not sure — Maybe over the last year or so.
Do you take any herbal supplements? Question
06/28/20 3:07 AM EDT
No, I don’t take anything herbal.
I do sometimes, yeah, when I go out with my friends.
How many drinks do you have when you go out at night? Question
06/28/20 3:58 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.
That’s moderate drinking, which is okay. Educate
06/28/20 4:38 PM EDT
Alright, thanks for letting me know.
What type of alcohol do you take? Question
06/28/20 4:39 PM EDT
I usually get rum and diet Coke. I don’t know why that matters.
How is your family medical history? (Clarified to Can you tell me about your family medical history?.) Question
06/28/20 4:45 PM EDT
My mom has some issues, and I think some of my grandparents did, too. (Clarified to to tell you about my family medical history.)
Question
06/28/20 6:25 PM EDT
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.
How did you cope with your father’s death? Question
06/28/20 6:25 PM EDT
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.
Seems you have a strong support system. Empathize
06/28/20 6:32 PM EDT
Thanks.
What health issues does your sister have? Question
06/28/20 6:34 PM EDT
She’s pretty healthy. She has asthma too, but she almost never has attacks.
What health issues does your brother have? Question
06/28/20 6:40 PM EDT
None that I know of. He’s got some extra weight on him, I guess.
Anyone with obesity in your family? Question
06/28/20 6:47 PM EDT
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.
Anyone with alcoholism in your family? Question
06/28/20 7:11 PM EDT
One person in the family, my dad’s brother, has an alcohol problem, but we never see him.
What work do you do? Question
06/28/20 7:14 PM 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.
Am glad to hear that. Empathize
06/28/20 7:14 PM EDT
Thanks for saying that.
What is your highest level of education? Question
06/28/20 7:15 PM EDT
Well, I’m finishing up my Bachelor’s degree right now.
Any fever? Question
06/28/20 7:19 PM EDT
No, I haven’t felt feverish at all this week. That’s another reason why this seems more like allergies than a cold.
Any dizziness? Question
06/28/20 7:24 PM EDT
I’m not feeling dizzy, no.
Any eye discharge? Question
06/28/20 7:24 PM EDT
Well, they’ve been watery.
When do you get blurry vision? Question
06/28/20 7:25 PM EDT
Usually when I’m reading.
Do you have red eyes? Question
06/28/20 7:27 PM EDT
Yeah, my eyes have been kinda red. They look the way they do when I’m around a cat, but I haven’t been near one.
Have you travelled abroad for more than one month? Question
06/28/20 7:29 PM EDT
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.
Am sure when you get less busy, you will travel more. Empathize
06/28/20 7:30 PM EDT
I appreciate you telling me that.
Any wheezing? Question
06/28/20 7:31 PM EDT
No, I’m not wheezing.
Thanks for answering my questions, let me now conduct physical exam. Educate
06/28/20 7:38 PM EDT
Thanks for telling me.
 Inspected general face Exam Action
06/28/20 7:43 PM EDT
 Inspected forehead and scalp Exam Action
06/28/20 7:46 PM EDT
 Inspected nose and mouth Exam Action
06/28/20 7:56 PM EDT
 Inspected right side of face Exam Action
06/28/20 7:56 PM EDT
 Inspected back of head Exam Action
06/28/20 7:57 PM EDT
 Inspected left side of face Exam Action
06/28/20 7:57 PM EDT
 Inspected general face Exam Action
06/28/20 8:05 PM EDT
 Inspected upper conjunctiva Exam Action
06/28/20 8:07 PM EDT
 Inspected right orbital area and sclera Exam Action
06/28/20 8:07 PM EDT
 Inspected left orbital area and sclera Exam Action
06/28/20 8:07 PM EDT
 Inspected lower conjunctiva Exam Action
06/28/20 8:07 PM EDT
 Performed otoscopic examination of right naris Exam Action
06/28/20 8:07 PM EDT
 Performed otoscopic examination of left naris Exam Action
06/28/20 8:08 PM EDT
 Performed otoscopic examination of right ear Exam Action
06/28/20 8:08 PM EDT
 Performed otoscopic examination of left ear Exam Action
06/28/20 8:08 PM EDT
 Inspected mouth Exam Action
06/28/20 8:08 PM EDT
 Inspected mouth: pushed tongue left with tongue blade Exam Action
06/28/20 8:08 PM EDT
 Inspect mouth: pushed tongue right with tongue blade Exam Action
06/28/20 8:08 PM EDT
 Inspect mouth: lifted tongue with tongue blade Exam Action
06/28/20 8:09 PM EDT
 Inspected mouth: depressed tongue with tongue blade Exam Action
06/28/20 8:09 PM EDT
 Inspected front of neck Exam Action
06/28/20 8:09 PM EDT
 Inspected right side of neck Exam Action
06/28/20 8:09 PM EDT
 Inspected back of neck Exam Action
06/28/20 8:09 PM EDT
 Inspected left side of neck Exam Action
06/28/20 8:09 PM EDT
 Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported Exam Action
06/28/20 8:10 PM EDT
 Palpated frontal sinuses: No tenderness reported Exam Action
06/28/20 8:10 PM EDT
 Palpated maxillary sinuses: No tenderness reported Exam Action
06/28/20 8:10 PM EDT
 Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+ Exam Action
06/28/20 8:11 PM EDT
 Palpated right carotid artery: No thrill, 2+ Exam Action
06/28/20 8:11 PM EDT
 Palpated left carotid artery: No thrill, 2+ Exam Action
06/28/20 8:11 PM EDT
 Palpated jaw: Full range of motion, no popping or clicking Exam Action
06/28/20 8:12 PM EDT
 Palpated lymph nodes of head and neck: Not palpable Exam Action
06/28/20 8:13 PM EDT
 Palpated supraclavicular lymph nodes: Not palpable Exam Action
06/28/20 8:13 PM EDT
 Palpated axillary lymph nodes: Not palpable Exam Action
06/28/20 8:13 PM EDT
 Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported Exam Action
06/28/20 8:14 PM EDT
 Auscultated breath sounds in anterior right upper lobe Exam Action
06/28/20 8:15 PM EDT
 Auscultated breath sounds in anterior right middle lobe Exam Action
06/28/20 8:15 PM EDT
 Auscultated breath sounds in anterior left upper lobe Exam Action
06/28/20 8:15 PM EDT
 Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action
06/28/20 8:16 PM EDT
 Auscultated breath sounds in anterior left lower lobe Exam Action
06/28/20 8:16 PM EDT
 Auscultated breath sounds in anterior right lower lobe Exam Action
06/28/20 8:17 PM EDT
 Auscultated breath sounds in posterior left upper lobe Exam Action
06/28/20 8:17 PM EDT
 Auscultated breath sounds in posterior right upper lobe Exam Action
06/28/20 8:17 PM EDT
 Auscultated breath sounds in posterior left mid-back (lower lobe) Exam Action
06/28/20 8:17 PM EDT
 Auscultated breath sounds in posterior right mid-back (lower lobe) Exam Action
06/28/20 8:18 PM EDT
 Auscultated breath sounds in posterior left lower lobe Exam Action
06/28/20 8:18 PM EDT
 Auscultated breath sounds in posterior left lower lobe on side Exam Action
06/28/20 8:18 PM EDT
 Auscultated breath sounds in posterior left lower lobe near spine Exam Action
06/28/20 8:18 PM EDT
 Auscultated breath sounds in posterior right lower lobe Exam Action
06/28/20 8:18 PM EDT
 Auscultated breath sounds in posterior right lower lobe near spine Exam Action
06/28/20 8:18 PM EDT
 Auscultated breath sounds in posterior right lower lobe on side Exam Action
06/28/20 8:18 PM EDT
 Auscultated right temporal pulse Exam Action
06/28/20 8:18 PM EDT
 Auscultated left temporal pulse Exam Action
06/28/20 8:18 PM EDT
 Auscultated right carotid pulse Exam Action
06/28/20 8:19 PM EDT
 Auscultated left carotid pulse Exam Action
06/28/20 8:19 PM EDT
 Tested left pupillary reaction with penlight Exam Action
06/28/20 8:19 PM EDT
 Tested right pupillary reaction with penlight Exam Action
06/28/20 8:19 PM EDT
Follow my finger with just your eyes Question
06/28/20 8:31 PM EDT
Ok.
 Tested EOM to the upper left Exam Action
06/28/20 8:31 PM EDT
 Tested EOM to the lower left Exam Action
06/28/20 8:31 PM EDT
 Tested EOM to the upper center Exam Action
06/28/20 8:31 PM EDT
 Tested convergence to the center Exam Action
06/28/20 8:31 PM EDT
 Tested EOM to the lower center Exam Action
06/28/20 8:31 PM EDT
 Tested EOM to the upper right Exam Action
06/28/20 8:32 PM EDT
 Tested EOM to the lower right Exam Action
06/28/20 8:32 PM EDT
Tell me when you can no longer see my fingers. Question
06/28/20 8:32 PM EDT
Ok, I will.
 Tested peripheral vision Exam Action
06/28/20 8:32 PM EDT
Now.
 Examined fundus of right eye with ophthalmoscope Exam Action
06/28/20 8:33 PM EDT
 Examined fundus of left eye with ophthalmoscope Exam Action
06/28/20 8:40 PM EDT
F P
T O Z
L P E D
P E C F D
 Tested visual acuity of right eye (left eye covered) Exam Action
06/28/20 8:42 PM EDT
F P
T O Z
L P E D
P E C F D
E D F C Z P
F E L O P Z D
D E F P O T E C
 Tested visual acuity of left eye (right eye covered) Exam Action
06/28/20 8:50 PM EDT
D E F P O T E C
 Tested visual acuity of left eye (right eye covered) Exam Action
06/28/20 8:50 PM EDT
Is the volume the same in both ears or louder in one ear Question
06/28/20 8:52 PM EDT
Ok.
Same in both ears.
 Performed Weber test with tuning fork Exam Action
06/28/20 8:52 PM EDT
Tell me when you no longer hear the ringing Question
06/28/20 8:53 PM EDT
Ok, I will.
Now.
 Performed Rinne test on right ear with tuning fork Exam Action
06/28/20 8:53 PM EDT
Now.
Now.
Now.
 Performed Rinne test on left ear with tuning fork Exam Action
06/28/20 8:54 PM EDT
F. Question
06/28/20 8:55 PM EDT
F.
Eight Question
06/28/20 8:55 PM EDT
Eight.
W. Question
06/28/20 8:55 PM EDT
W.
 Performed whisper test in right ear Exam Action
06/28/20 8:55 PM EDT
Four Question
06/28/20 8:55 PM EDT
Four.
R. Question
06/28/20 8:55 PM EDT
R.
Nine. Question
06/28/20 8:55 PM EDT
Nine.
 Performed whisper test in left ear Exam Action
06/28/20 8:55 PM EDT
 Tested gag reflex with tongue blade Exam Action
06/28/20 8:56 PM EDT

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