ASSIGNMENT 4.1 SHADOW HEALTH TINA JONES HEENT TRANSCRIPT, Exams of Nursing

Download ASSIGNMENT 4.1 SHADOW HEALTH TINA JONES HEENT TRANSCRIPT and more Exams Nursing in PDF only on Docsity! ASSIGNMENT 4.1 SHADOW HEALTH TINA JONES HEENT TRANSCRIPT 2021 Hey. Question 09/10/21 What brought you to the clinic today? My throat has been sore... and itchy. And my nose won't stop running. These symptoms are driving me nuts. I appreciate you telling me that. 2:09 PM CDT How long have you been experiencing these symptoms? My itchy eyes, runny nose, and sore throat all started a week ago. [AUDIO COMING SOON] Question 09/10/21 2:12 PM CDT Have you ever had these symptoms before? No. Question 09/10/21 2:13 PM CDT How severe is your sore throat? It's not... terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won't go away. Thanks for understanding. Question 09/10/21 2:13 PM CDT Can you rate the sore throat pain? Maybe like a 5 in the morning and a 4 the rest of the time. Question 09/10/21 2:15 PM CDT Does the pain from your throat radiate? (Clarified to Tell me about your throat pain?.) 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. (Clarified to to tell you about my throat pain.) Question 09/10/21 2:16 PM CDT Does anything make your throat pain better? (Clarified to What helps the Question throat pain?.) I've been trying throat drops, and drinking water but that's it. (Clarified to what makes my throat pain better.) 09/10/21 2:16 PM CDT What aggravates the throat pain? Well, my throat's usually worse in the mornings, and swallowing can make it sore, too. [AUDIO COMING SOON] Question 09/10/21 2:16 PM CDT Do you have any nasal discharge? Yes, it won't stop running! Question 09/10/21 2:17 PM CDT What color is the mucus? It's just clear. Question 09/10/21 2:17 PM CDT Do you have any eye symptoms? 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. Thanks. Question 09/10/21 2:17 PM CDT Are you taking any other medication? Just my inhaler. And some throat drops. Question 09/10/21 2:24 PM CDT Have you taken any over the counter tylenol? I've been using throat drops, like lozenges, for my sore throat. Other than that, I just have my inhaler. Question 09/10/21 2:25 PM CDT Are you having any drainage from your ears? Question 09/10/21 2:25 PM CDT Not that I've noticed. Are you having any ear pain? No, my ears don't hurt. Question 09/10/21 2:25 PM CDT How much water are you drinking a day? I don't really keep track of how much, but I've been drinking a lot of water lately. Way more than usual. Question 09/10/21 2:30 PM CDT Are you having any headaches? Yeah, I get them a lot when I'm studying. Thanks for saying that. Question 09/10/21 2:31 PM CDT How often are you getting headache? 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. I appreciate you saying that. Question 09/10/21 2:32 PM CDT Can you rate the pain that you have with your headaches? Not too bad. . . I'd say about 3. Or a 4 if I really push it. Question 09/10/21 2:33 PM CDT What makes your headaches better? I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON] Question 09/10/21 2:33 PM CDT How many tablets of the acetaminophen 500 mg do you take at a time? Question 09/10/21 2:34 PM CDT I take the extra-strength acetaminophen, the gel kind, 500 mg. It's what we usually have around the house. [AUDIO COMING SOON] Thanks for saying that. OK, I understand. Does anything make your headaches worse? 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. Thanks for understanding. Question 09/10/21 2:37 PM CDT How long have you been having these headaches? I'm not sure -- Maybe over the last year or so. Question 09/10/21 2:38 PM CDT Have you seen a doctor for your headaches? No, I never felt like I needed to. Question 09/10/21 2:38 PM CDT Have you seen an optometrist for your vision changes? Yeah, when I was a kid. I got eye tests from the school nurse. But I haven't had an eye exam since. Thanks for telling me. Question 09/10/21 2:39 PM CDT Do you take any herbal medication? No, I don't take anything herbal. Question 09/10/21 2:40 PM CDT Do you have any allergies to medications? Question 09/10/21 2:40 PM CDT Yeah, I'm allergic to penicillin. What happens when you take penicillin? 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. Question 09/10/21 2:41 PM CDT How severe were your hives? (Clarified to Where did you have penicillin hives?.) The doctor said I got hives when I took it, but I don't know where the rash was. Probably all over. (Clarified to where I had the penicillin hives.) Question 09/10/21 2:41 PM CDT Was the rash mild? (No matching questions found.) Question 09/10/21 2:41 PM CDT 2:51 PM CDT I went a bunch of times when I was little, for asthma attacks. Question 09/10/21 Any other hospital visits? 2:52 PM CDT Well, I was in the ER a little over a month ago, for my foot. Question 09/10/21 Tell me what happened to your foot. 2:52 PM CDT I scraped it up pretty bad a while ago. It got infected, too. [AUDIO COMING SOON] Thanks for saying that. Question 09/10/21 Do you need me to examine your foot? (No matching questions found.) 2:53 PM CDT Question 09/10/21 Is your foot ok now? 2:53 PM CDT My foot is doing great. It doesn't hurt at all, and the scrape is healed up. I'm glad that's all over with. Thanks. Question 09/10/21 Do you have any other medical problems? I have diabetes and asthma, but I can't even deal with those today. I appreciate you saying that. 2:54 PM CDT What kind of diabetes do you have? It's Type 2. Question 09/10/21 2:55 PM CDT Do you take any medication for your diabetes? I don't take anything for my diabetes anymore. Alright, thanks for letting me know. Question 09/10/21 2:55 PM CDT Will you please tell me why you are not taking your diabetic medication any longer? (Clarified to Why did you stop taking diabetes medication?.) I just got sick of dealing with it! (Clarified to why I stopped taking my diabetes medication.) Question 09/10/21 2:57 PM CDT What did you get sick of? I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. I appreciate you telling me that. That makes sense. Question 09/10/21 2:57 PM CDT What medicine were you taking for your diabetes? Question 09/10/21 2:58 PM CDT It was Metformin. Question 09/10/21 Do you remember the milligrams of your metformin? Honestly, I don't remember what the dose was when I was taking it. 2:59 PM CDT How often did you take the metformin? I think it was one pill, twice a day. Question 09/10/21 2:59 PM CDT Do you remember what your last hemoglobin A1c was? (Clarified to Do you know your latest blood sugar number?.) ...No... to be honest, I almost never check it. I know I'm supposed to. (Clarified to if I know my latest blood sugar number.) Thanks. Question 09/10/21 3:00 PM CDT When do you normally check your blood sugar? I know this is bad, but I haven't checked it in a long time. Like... Maybe the last time was more than a month ago, when I was in the ER to get my foot looked at. Question 09/10/21 3:00 PM CDT Do you remember what your blood sugar number was when you were in the ER a month ago? ...I really don't know. I don't really check it. Question 09/10/21 3:01 PM CDT Have you ever had any surgery? Nope. No surgeries... I've been lucky. Question 09/10/21 3:01 PM CDT Have you had any childhood diseases like chickenpox? Question 09/10/21 3:01 PM CDT Well, I got the usual stuff, like chicken pox. . . and I had the asthma, too. Question 09/10/21 Have you had the measles? No, I never got that as a kid. 3:02 PM CDT Have you had the mumps? No, I never got that as a kid. Question 09/10/21 3:02 PM CDT How many drinks of alcohol with Diet Coke do you think you have a month? Oh, I don't know. Let's see... I might go out every few weeks, so twice a month... and I maybe have 2 or 3 drinks at a time, so maybe 6 drinks a month. Even if I go out more than usual, no more than ten. Question 09/10/21 3:11 PM CDT How does drinking alcohol make you feel? It's fun to go out for drinks with my friends, but it's not, like, a huge part of my life or anything. Question 09/10/21 3:12 PM CDT Do you use recreational drugs? No. Question 09/10/21 3:13 PM CDT When you are with your friends, do your friends use recreational drugs? No. No one that I'm friends with does that stuff anymore. Question 09/10/21 3:13 PM CDT Are you currently in a relationship? Um, not right now. Question 09/10/21 3:14 PM CDT Are you sexually active? Um, not right now. Question 09/10/21 3:14 PM CDT Are you using any form of birth control for when you are sexually active? Question 09/10/21 3:14 PM CDT Nope. But I've been single for a while so I haven't needed to. Alright, thanks for letting me know. Question 09/10/21 Are you having any problems with your heart? 3:16 PM CDT No, my heart's always been fine. Question 09/10/21 Have you had bronchitis? 3:16 PM CDT Nope, never. Question 09/10/21 Have you had pneumonia? 3:16 PM CDT Nope, never. Question 09/10/21 Have you had any problems with your stomach? 3:20 PM CDT I don't get stomachaches very easily. Question 09/10/21 Any problems with your intestines? 3:20 PM CDT I don't really get stomach problems. Question 09/10/21 When was your last bowel movement? 3:20 PM CDT I haven't gone yet today, but I did last night. Question 09/10/21 Was your bowel movement last night normal? 3:20 PM CDT My bowels are fine. Question 09/10/21 Any diarrhea? 3:20 PM CDT I haven't had diarrhea in a long time. . . like, years. Question 09/10/21 Any nausea or vomiting? 3:21 PM CDT I haven't had thrown up, or even had an upset stomach, in a long time. Question 09/10/21 Any body aches? 3:21 PM CDT No. Question 09/10/21 Any chills? 3:21 PM CDT No. Question 09/10/21 Any flank pain? 3:21 PM CDT No. Question 09/10/21 Any difficulty urinating? 3:21 PM CDT It doesn't hurt when I pee or anything. Question 09/10/21 Any increase in urination? 3:22 PM CDT Yeah, but I've been drinking more water. Question 09/10/21 Any increase in hunger? Question 09/10/21 Do you know your dad's mother's health issues? Question 09/10/21 3:28 PM CDT She takes some blood pressure pills, and I think she has high cholesterol, but Granny's doing great for 82. Thanks for saying that. That makes sense. Question 09/10/21 What type of work do you do? I'm a supervisor at Mid-American Copy & Ship. I've been working there since high school, and I've just kept moving up. Thanks. 3:30 PM CDT Is your work stressful? I'd say that work exhausts me. I wouldn't say it stresses me out exactly. It's just...at the end of the day, I'm worn out. Question 09/10/21 3:30 PM CDT Does your job expose you to anything that could cause your symptoms? (No matching questions found.) Question 09/10/21 3:31 PM CDT What type of work do you do as a supervisor at Mid-American copy and ship? (No matching questions found.) Question 09/10/21 3:32 PM CDT Do you have health insurance? Work gives me health insurance, fortunately. Question 09/10/21 3:33 PM CDT What is your access to healthcare like? I have health insurance through my job, so I can go to the doctor if I need to. It's always a hassle though, so I try to avoid it unless I really have to like right now. Question 09/10/21 3:33 PM CDT Do you have trouble affording Healthcare? Question 09/10/21 3:33 PM CDT Question I'm in an OK place financially . . . without vision or dental insurance it's kind of tough, but my insurance covers most of my doctor's visits. [AUDIO COMING SOON] 09/10/21 Do you have trouble affording your medication? 3:34 PM CDT I don't have problems affording medication. I think my insurance covers most of it . . . back when I was on metformin it was only about $10 a month. I just stopped taking it because I got sick of the side effects. [AUDIO COMING SOON] I appreciate you telling me that. Question 09/10/21 May I complete my physical exam now? 3:34 PM CDT Sure. Question 09/10/21 Follow my finger with just your eyes 3:52 PM CDT Ok. Question 09/10/21 Tell me when you can no longer see my fingers 3:54 PM CDT Ok, I will. Now. F P F P 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 Have you noticed any acne scars? (Clarified to Do you have scars?.) I don't think I have any scars. I have some stretch marks, I guess, but that's all. (Clarified to if I have scars.) Question 09/10/21 4:37 PM CDT Do you have acne? Question 09/10/21 4:37 PM CDT I've been getting break-outs since I was in middle school, I think. Like around the time I started my period, my skin started to break out. It went away for a few years in my twenties, but now I'm getting zits again. Do you notice excessive hair growth? (Clarified to Have you had an increase in body hair?.) Yeah, I've noticed some hairs on my chin that I have to pluck, and I'm...I guess you can see that I'm kind of getting a mustache, which I hate. I'm embarrassed about it. I think I need to start waxing it... I have some belly hair, too. (Clarified to if I my body hair has increased.) Thanks for understanding. Question 09/10/21 4:38 PM CDT There could be an underlying hormonal imbalance. We can do some labs to verify this. (No matching questions found.) Alright, thanks for letting me know. Question 09/10/21 4:39 PM CDT Any rashes? I don't have any rashes. Question 09/10/21 4:39 PM CDT Do your eyelids feel swollen? (Clarified to Are your eyelids swollen?.) My eyes aren't really swollen. Just itchy. [AUDIO COMING SOON] (Clarified to if my eyelids are swollen.) Question 09/10/21 4:39 PM CDT Question Are you having and drainage from the eyes? Well, they've been watery. Question 09/10/21 4:40 PM CDT Do your eyes feel swollen? Question 09/10/21 4:43 PM CDT No, I don't think so. Now. 09/10/21 Is the volume the same in both ears or louder in one ear. 5:12 PM CDT Ok. Same in both ears. Question 09/10/21 Tell me when you no longer hear the ringing 5:13 PM CDT Ok, I will. Now. Now. Now.