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 |
| Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. | |
| What medical issues does your father have? (Clarified to Tell me about your dad’s health?.) | Question 05/29/20 7:36 PM EDT |
| He passed last year. (Clarified to what health issues my dad has.) | |
| Am sorry to hear that | Empathize 05/29/20 7:36 PM EDT |
| Thanks for understanding. | |
| did your father have any medical conditions? | Question 05/29/20 7:37 PM EDT |
| He had high blood pressure and cholesterol, and diabetes too…the same kind as me. | |
| What health issues does your maternal grandmother have? | Question 05/29/20 7:37 PM EDT |
| Nana had high blood pressure and cholesterol, I think. | |
| What issues does you maternal grandfather have? | Question 05/29/20 7:38 PM EDT |
| Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too. | |
| What health issues does you paternal grand mother have? | Question 05/29/20 7:38 PM EDT |
| 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. | |
| What health issues does your paternal grandfather have? | Question 05/29/20 7:39 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 fathers death? | Question 05/29/20 7:39 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 which is great. | Empathize 05/29/20 7:40 PM EDT |
| Thanks. | |
| What health conditions does your sister have? | Question 05/29/20 7:41 PM EDT |
| She’s pretty healthy. She has asthma too, but she almost never has attacks. | |
| what health conditions does your brother have? | Question 05/29/20 7:41 PM EDT |
| None that I know of. He’s got some extra weight on him, I guess. | |
| Anyone one with an obesity problem in your family? | Question 05/29/20 7:45 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. | |
| Any one with alcoholism problem in the family? | Question 05/29/20 7:46 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 05/29/20 7:47 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 happy to hear that your job is fine and you are doing well | Empathize 05/29/20 7:47 PM EDT |
| Thanks for understanding. | |
| What is your highest level of education? | Question 05/29/20 7:48 PM EDT |
| Well, I’m finishing up my Bachelor’s degree right now. | |
| What is your Major? | Question 05/29/20 7:48 PM EDT |
| I’m going to get my bachelor’s in accounting. | |
| ||
| 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 05/29/20 7:52 PM EDT |
| I appreciate you saying that. | |
| Have you been wheezing? | Question 05/29/20 7:52 PM EDT |
| No, I haven’t been wheezing this week. | |
| Please let me examine you now. (No matching questions found.) | Question 05/29/20 7:53 PM EDT |
| Please let me examine you now. | Educate 05/29/20 7:53 PM EDT |
| Sure, I think I understand what you mean. | |
| Inspected general face | Exam Action 05/29/20 7:57 PM EDT |
| Inspected forehead and scalp | Exam Action 05/29/20 7:58 PM EDT |
| Inspected nose and mouth | Exam Action 05/29/20 7:58 PM EDT |
| Inspected left side of face | Exam Action 05/29/20 7:58 PM EDT |
| Inspected back of head | Exam Action 05/29/20 7:58 PM EDT |
| Inspected right side of face | Exam Action 05/29/20 7:58 PM EDT |
| Inspected general face | Exam Action 05/29/20 7:58 PM EDT |
| Inspected right side of face | Exam Action 05/29/20 7:58 PM EDT |
| Inspected general face | Exam Action 05/29/20 7:58 PM EDT |
| Inspected nose and mouth | Exam Action 05/29/20 7:58 PM EDT |
| Inspected forehead and scalp | Exam Action 05/29/20 7:58 PM EDT |
| Inspected nose and mouth | Exam Action 05/29/20 7:58 PM EDT |
| Inspected right orbital area and sclera | Exam Action 05/29/20 7:59 PM EDT |
| Inspected lower conjunctiva | Exam Action 05/29/20 7:59 PM EDT |
| Inspected upper conjunctiva | Exam Action 05/29/20 8:00 PM EDT |
| Inspected upper conjunctiva | Exam Action 05/29/20 8:00 PM EDT |
| Inspected left orbital area and sclera | Exam Action 05/29/20 8:00 PM EDT |
| Performed otoscopic examination of right naris | Exam Action 05/29/20 8:00 PM EDT |
| Performed otoscopic examination of left naris | Exam Action 05/29/20 8:01 PM EDT |
| Performed otoscopic examination of right ear | Exam Action 05/29/20 8:02 PM EDT |
| Performed otoscopic examination of left ear | Exam Action 05/29/20 8:02 PM EDT |
| Inspected mouth | Exam Action 05/29/20 8:03 PM EDT |
| Inspected mouth: pushed tongue left with tongue blade | Exam Action 05/29/20 8:04 PM EDT |
| Inspect mouth: pushed tongue right with tongue blade | Exam Action 05/29/20 8:04 PM EDT |
| Inspect mouth: lifted tongue with tongue blade | Exam Action 05/29/20 8:04 PM EDT |
| Inspected mouth: depressed tongue with tongue blade | Exam Action 05/29/20 8:04 PM EDT |
| Inspected front of neck | Exam Action 05/29/20 8:06 PM EDT |
| Inspected left side of neck | Exam Action 05/29/20 8:06 PM EDT |
| Inspected back of neck | Exam Action 05/29/20 8:06 PM EDT |
| Inspected right side of neck | Exam Action 05/29/20 8:06 PM EDT |
| Inspected back of neck | Exam Action 05/29/20 8:06 PM EDT |
| Inspected right side of neck | Exam Action 05/29/20 8:07 PM EDT |
| Inspected front of neck | Exam Action 05/29/20 8:07 PM EDT |
| Inspected right side of neck | Exam Action 05/29/20 8:07 PM EDT |
| Inspected front of neck | Exam Action 05/29/20 8:07 PM EDT |
| Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported | Exam Action 05/29/20 8:07 PM EDT |
| Palpated maxillary sinuses: No tenderness reported | Exam Action 05/29/20 8:08 PM EDT |
| Palpated frontal sinuses: No tenderness reported | Exam Action 05/29/20 8:08 PM EDT |
| Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+ | Exam Action 05/29/20 8:08 PM EDT |
| Palpated right carotid artery: No thrill, 2+ | Exam Action 05/29/20 8:10 PM EDT |
| Palpated left carotid artery: No thrill, 2+ | Exam Action 05/29/20 8:10 PM EDT |
| Palpated jaw: Full range of motion, no popping or clicking | Exam Action 05/29/20 8:11 PM EDT |
| Palpated axillary lymph nodes: Not palpable | Exam Action 05/29/20 8:11 PM EDT |
| Palpated supraclavicular lymph nodes: Not palpable | Exam Action 05/29/20 8:12 PM EDT |
| Palpated lymph nodes of head and neck: Not palpable | Exam Action 05/29/20 8:12 PM EDT |
| Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported | Exam Action 05/29/20 8:12 PM EDT |
| Auscultated breath sounds in anterior right lower lobe | Exam Action 05/29/20 8:13 PM EDT |
| Auscultated breath sounds in anterior right middle lobe | Exam Action 05/29/20 8:13 PM EDT |
| Auscultated breath sounds in anterior right upper lobe | Exam Action 05/29/20 8:13 PM EDT |
| Auscultated breath sounds in anterior left upper lobe | Exam Action 05/29/20 8:13 PM EDT |
| Auscultated breath sounds in anterior left mid-chest (upper lobe) | Exam Action 05/29/20 8:13 PM EDT |
| Auscultated breath sounds in anterior left lower lobe | Exam Action 05/29/20 8:13 PM EDT |
| Auscultated breath sounds in posterior left upper lobe | Exam Action 05/29/20 8:13 PM EDT |
| Auscultated breath sounds in posterior left mid-back (lower lobe) | Exam Action 05/29/20 8:13 PM EDT |
| Auscultated breath sounds in posterior left lower lobe | Exam Action 05/29/20 8:13 PM EDT |
| Auscultated breath sounds in posterior left lower lobe on side | Exam Action 05/29/20 8:13 PM EDT |
| Auscultated breath sounds in posterior left lower lobe near spine | Exam Action 05/29/20 8:13 PM EDT |
| Auscultated breath sounds in posterior right lower lobe near spine | Exam Action 05/29/20 8:14 PM EDT |
| Auscultated breath sounds in posterior right lower lobe on side | Exam Action 05/29/20 8:14 PM EDT |
| Auscultated breath sounds in posterior right lower lobe | Exam Action 05/29/20 8:14 PM EDT |
| Auscultated breath sounds in posterior right mid-back (lower lobe) | Exam Action 05/29/20 8:14 PM EDT |
| Auscultated breath sounds in posterior right upper lobe | Exam Action 05/29/20 8:14 PM EDT |
| Auscultated right temporal pulse | Exam Action 05/29/20 8:14 PM EDT |
| Auscultated left temporal pulse | Exam Action 05/29/20 8:14 PM EDT |
| Auscultated right carotid pulse | Exam Action 05/29/20 8:15 PM EDT |
| Auscultated left carotid pulse | Exam Action 05/29/20 8:15 PM EDT |
| Tested left pupillary reaction with penlight | Exam Action 05/29/20 8:16 PM EDT |
| Tested right pupillary reaction with penlight | Exam Action 05/29/20 8:16 PM EDT |
| Follow my finger with just your eyes | Question 05/29/20 8:17 PM EDT |
| Ok. | |
| Tested EOM to the upper right | Exam Action 05/29/20 8:17 PM EDT |
| Tested EOM to the lower right | Exam Action 05/29/20 8:17 PM EDT |
| Tested EOM to the lower center | Exam Action 05/29/20 8:17 PM EDT |
| Tested convergence to the center | Exam Action 05/29/20 8:17 PM EDT |
| Tested EOM to the upper center | Exam Action 05/29/20 8:17 PM EDT |
| Tested EOM to the upper left | Exam Action 05/29/20 8:17 PM EDT |
| Tested EOM to the lower left | Exam Action 05/29/20 8:17 PM EDT |
| Tell me when you can no loner see | Question 05/29/20 8:18 PM EDT |
| Ok, I will. | |
| Tested peripheral vision | Exam Action 05/29/20 8:18 PM EDT |
| Now. | |
| Examined fundus of right eye with ophthalmoscope | Exam Action 05/29/20 8:20 PM EDT |
| Examined fundus of left eye with ophthalmoscope | Exam Action 05/29/20 8:21 PM EDT |
| F P | |
| Is the volume the same in both ears or louder in one ear | Question 05/29/20 8:24 PM EDT |
| Ok. | |
| Same in both ears. | |
| Performed Weber test with tuning fork | Exam Action 05/29/20 8:25 PM EDT |
| Tell me when you no longer hear the ringing | Question 05/29/20 8:25 PM EDT |
| Ok, I will. | |
| Now. | |
| F. | Question 05/29/20 8:26 PM EDT |
| F. | |
| Eight | Question 05/29/20 8:26 PM EDT |
| Eight. | |
| W. | Question 05/29/20 8:26 PM EDT |
| W. | |
| Performed whisper test in right ear | Exam Action 05/29/20 8:26 PM EDT |
| Four | Question 05/29/20 8:26 PM EDT |
| Four. | |
| R. | Question 05/29/20 8:26 PM EDT |
| R. | |
| Nine. | Question 05/29/20 8:26 PM EDT |
| Nine. | |
| Performed whisper test in left ear | Exam Action 05/29/20 8:27 PM EDT |
| Tested gag reflex with tongue blade | Exam Action 05/29/20 8:27 PM EDT |
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