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A simulated patient interview and physical exam transcript for tina jones, a 28-year-old woman with a history of asthma and diabetes. The transcript includes questions asked by the interviewer, tina's responses, and relevant medical information. It provides insights into tina's health status, lifestyle, and medical history, making it a valuable resource for healthcare professionals and students studying patient interactions.
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Transcript
All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Greet
Hello, my name is Tammy. I will be conducting an interview and a physical exam.
Hey.
What is your name?
Tina Jones.
What is your date of birth?
February 17th.
How old are you?
I’m 28.
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What brings you into the clinic today?
I came in because I’m required to have a recent physical exam for the health insurance at my new job.
Do you have any current health problem?
I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I’m taking good care of my health these days.
What is your new job?
I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks–I’m really excited!
That is great.
Thanks.
When was your last physical exam?
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Let’s see... I had two doctor’s appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.
What did your gynecologist say?
She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things.
How often do you take birth control?
I take it every morning, with breakfast.
What is the name of the birth control pill you took?
They’re called Yaz.
Has your menstrual cycle improved since taking Yaz?
Now that I’m on the pill I’m getting my period every month.
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That is great. I am glad you are having your period every month.
Thanks.
How long have you had asthma?
I’ve had asthma a long time... since I was really little.
What age were you diagnosed with asthma?
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.
I am sorry about the experienc e.
Thanks.
How do you manage your asthma?
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I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
What are your triggers for asthma?
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.
It is important to stay away from triggers.
Thanks for telling me.
What happens when you are around dust?
I used to have a reaction when I was in a dusty house for a long time... I would get allergies, like sneezing and stuff, and then my
asthma would act up. But that hasn’t happened since I got my daily inhaler.
What inhaler do you use?
The daily inhaler is Flovent, and the rescue inhaler is Proventil.
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How often do you use Flovent?
Twice a day.
When did you most recently use the Flovent inhaler?
I use my Flovent inhaler two times a day.
When did you last use your inhaler?
I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol... I’ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too.
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How much Albuterol do you use?
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I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church.
What is your relationship like with your family?
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Things are pretty good between all of us–we’re a tight knit family. I think we’re pretty special, the way we all get along.
That is great.
Thanks.
Are you involved in church?
Yeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too.
Are you feeling stressed?
I’m actually feeling really good lately... not stressed at all.
How do you cope with stress?
I’ve realized that I got kind of overwhel med with everythin g back when I was having those sleep problems. Just coming in and talkingto someone here about it helped a little because I felt like I was doing something
. So I’ve been trying to address problems as they come when I
can, and that helps. That, plus the stuff I’ve always done–going to church, especially–is all working well for me.
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That is good to hear.
Thanks.
Are you feeling depressed?
No, I’m actually feeling really good these days.
How do you feel about your life?
Well, I’m starting my new job in two weeks, and I’m really excited about that. I’m going to be an Accounting Clerk at this really nice accounting firm. I’m hoping I’ll learn a lot in that position, and within a couple years, I’ll get promoted and be given new responsibilities. I just always want to be learning new things and getting better at my job.
Are you feeling anxious?
I guess I had anxiety back when I was having those sleep problems
.. . I’ve been feeling much better lately, though.
Do you have sleeping problems ?
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I’m sleeping a lot better now, which is a relief.
Good to hear.
Thanks.
How many hours are you sleeping a night?
I’m usually asleep by 11:30, and I wake up at 8, so... about 8 or 9 hours a night.
That is great.
Thanks.
Have you ever smoked tobacco?
No. I think it’s gross.
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Have you ever used cocaine?
No way, I have no interest in that. That stuff can mess you up.
Have you ever used heroin?
Uh, no.
Have you ever used illegal drugs?
Well, I used to smoke pot... but I don’t do that anymore.
What was the last time you smoked pot?
I haven’t smoked pot since I was twenty or twenty- one.
Do you have any family history of mental illness?
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No. They’re crazy, but nobody’s diagnosed with anything.
Have you had suicidal thoughts?
No, I’ve never done that.
Any new family medical history report?
My mom has some issues, and I think some of my grandparents did, too.
How old is your mom?
Mom is 50.
What medical problems does your mum have?
Mom has high cholester ol and blood pressure, I think. She seems to be doing okay though.
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What medical problems did your father have?
He had high blood pressure and cholesterol, and diabetes too…the same kind as me.
How old is your brother?
He’s almost 27.
Does he have any medical issue? (Clarified to Does your younger sister have health problems?.)
She’s pretty healthy. She has asthma too, but she almost never has attacks. (Clarified to if my younger sister has health problems.)
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Does your bother have health issues? (Clarified to Does your brother 07/23/20
have medical problems?.)
No, I don’t think so. He’s a little big, maybe. (Clarified to if my brother has health issues.)
How old is your maternal grandmother?
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