Comprehensive Assessment SH Transcript, Sub, Obj & Documentation
Transcript
Hello, my name is . I will be conducting an interview and later perform a physical exam. Hey.
What is your name? Tina Jones
Your date of birth? February 17th.
How old are you? I’m 28.
What brought 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. Empathize Your text here 1
Thanks.
When was your last physical exam? 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.
That is great. I am glad you are having your period every month. Empathize
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 experience. Empathize
Thanks.
How do you manage your asthma? 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. Educate
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.
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.
How much Albuterol do you use? 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?
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. Empathize
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 overwhelmed with everything back when I was having those sleep
problems. Just coming in and talking to 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.
That is good to hear. Empathize
Thanks.
Are you feeling depressed? No, I’m actually feeling really good these days.
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, 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? I’m sleeping a lot better now, which is a relief.
Good to hear. Empathize
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. Empathize
Thanks.
Have you ever smoked tobacco? No. I think it’s gross.
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?
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 cholesterol and blood pressure, I think. She seems to be doing okay though.
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.)
Does your bother have health issues? (Clarified to Does your brother 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?
Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.
How old is your maternal grandfather?
Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
Any medical history for your paternal grandmother?
She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82.
Does your dad’s father have health issues?
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.
Have you had any recent illness?
No. . . the last time I was sick was when I was having those heartburn problems a while ago.
Any fever?
I haven’t had a fever.
Any chills?
Nope, no chills.
Any acne?
I took something for my acne. . . tetracycline, I think, back in high school. Since then I’ve just washed my face, I haven’t used anything
special. But my zits have gotten better, and I think it’s because I’m on birth control now.
Has your body hair improved?
I think I have a little less body hair than I used to.
Do your eyes feel itchy?
They haven’t been itchy lately at all.
Are you having any redness in your eyes?
MyThis
eyes haven’t been red lately. . . not since I came in with those allergies a while ago.
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Transcript
Hello, my name is . I will be conducting an interview and later perform a physical exam. Hey.
What is your name? Tina Jones
Your date of birth? February 17th.
How old are you? I’m 28.
What brought 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. Empathize Your text here 1
Thanks.
When was your last physical exam? 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.
That is great. I am glad you are having your period every month. Empathize
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 experience. Empathize
Thanks.
How do you manage your asthma? 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. Educate
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.
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.
How much Albuterol do you use? 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?
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. Empathize
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 overwhelmed with everything back when I was having those sleep
problems. Just coming in and talking to 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.
That is good to hear. Empathize
Thanks.
Are you feeling depressed? No, I’m actually feeling really good these days.
This study source was downloaded by 100000842722785 from CourseHero.com on 05-20-2022 05:32:22 GMT -05:00
https://www.coursehero.com/file/83744008/COMPREHENSIVE-ASSESSMENT-TINA-JONES-SHdocx/
, 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? I’m sleeping a lot better now, which is a relief.
Good to hear. Empathize
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. Empathize
Thanks.
Have you ever smoked tobacco? No. I think it’s gross.
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?
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 cholesterol and blood pressure, I think. She seems to be doing okay though.
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.)
Does your bother have health issues? (Clarified to Does your brother 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?
Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.
How old is your maternal grandfather?
Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
Any medical history for your paternal grandmother?
She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82.
Does your dad’s father have health issues?
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.
Have you had any recent illness?
No. . . the last time I was sick was when I was having those heartburn problems a while ago.
Any fever?
I haven’t had a fever.
Any chills?
Nope, no chills.
Any acne?
I took something for my acne. . . tetracycline, I think, back in high school. Since then I’ve just washed my face, I haven’t used anything
special. But my zits have gotten better, and I think it’s because I’m on birth control now.
Has your body hair improved?
I think I have a little less body hair than I used to.
Do your eyes feel itchy?
They haven’t been itchy lately at all.
Are you having any redness in your eyes?
MyThis
eyes haven’t been red lately. . . not since I came in with those allergies a while ago.
study source was downloaded by 100000842722785 from CourseHero.com on 05-20-2022 05:32:22 GMT -05:00
Are your eyes dry?
https://www.coursehero.com/file/83744008/COMPREHENSIVE-ASSESSMENT-TINA-JONES-SHdocx/
