Tina Jones Health History
shadow health Tina Jones Health History transcript
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Started: Nov 02, 2021 | Total Time: 399 min
 | Height: 170 cm | Exam Action 11/02/21 4:28 AM EDT |
| Weight: 90 kg | Exam Action 11/02/21 4:28 AM EDT |
| BMI: 31 | Exam Action 11/02/21 4:28 AM EDT |
| Random blood glucose: 238 | Exam Action 11/02/21 4:28 AM EDT |
| Temperature: 101.1 F | Exam Action 11/02/21 4:28 AM EDT |
| Blood pressure: 142/82 | Exam Action 11/02/21 4:28 AM EDT |
| Respiratory rate: 19 | Exam Action 11/02/21 4:28 AM EDT |
| O2 sat: 99% | Exam Action 11/02/21 4:28 AM EDT |
| Heart rate: 86 | Exam Action 11/02/21 4:28 AM EDT |
| Measured wound: 2 cm x 1.5 cm, 2.5 mm deep | Exam Action 11/02/21 4:32 AM EDT |
| Swabbed wound and sent to lab for C & S | Exam Action 11/02/21 4:32 AM EDT |
| Cleansed and irrigated wound with normal saline and applied dry sterile dressing. | Exam Action 11/02/21 4:32 AM EDT |
| Hello.My name is Gisselle. i will interview you and later examine you. | Question 11/02/21 4:33 AM EDT |
 | Hello. | |
| Hello. Mt name is xxx, I will interview you and later examine you. | Greet 11/02/21 5:19 PM EDT |
| Hey. | |
| What is your name? | Question 11/02/21 5:19 PM EDT |
| Tina Jones. | |
| Why are you here today? | Question 11/02/21 5:20 PM EDT |
| I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me! | |
| Am sorry hear that. | Empathize 11/02/21 5:20 PM EDT |
| I appreciate you telling me that. | |
| When did you get the scrape? | Question 11/02/21 5:20 PM EDT |
| Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days. | |
| How severe is the pain? | Question 11/02/21 5:21 PM EDT |
| It’s really bad. | |
| Can you describe the pain? | Question 11/02/21 5:21 PM EDT |
| It’s throbbing and like, sharp if I try to put weight on it. | |
| Did you hurt any other part? (Clarified to Did you hurt anything else during the fall?.) | Question 11/02/21 5:22 PM EDT |
| Well, at first I thought my ankle was sprained because it hurt a lot right after I fell. But, I mean, I guess I was over-estimating it, because the ankle felt pretty okay the next day and it wasn’t a problem all week. (Clarified to if I hurt anything else during the fall.) | |
| How has the pain changed over time? | Question 11/02/21 5:23 PM EDT |
| At first, it seemed like it was healing up fine and it didn’t give me a lot of pain. But the last two days, the pain got way worse. | |
| Does the pain radiate? | Question 11/02/21 5:23 PM EDT |
| The pain’s worse in my foot, but I feel it moving up into my ankle, too. | |
| How did you hurt your ankle? | Question 11/02/21 5:24 PM EDT |
| I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step. | |
| Can you stand on your foot? | Question 11/02/21 5:25 PM EDT |
| No, I can’t put weight on my foot without really sharp pain. | |
| Can you rate your pain on a scale of 0 to 10? | Question 11/02/21 5:25 PM EDT |
| I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet. | |
| Where is the pain located? | Question 11/02/21 5:26 PM EDT |
| It feels like the pain is just centered around the scrape, like around the ball of my foot. That’s where it hurts the most, but my whole foot feels some pain. | |
| Which foot did you injure? | Question 11/02/21 5:26 PM EDT |
| My right foot. | |
| Were you wearing shoes? | Question 11/02/21 5:26 PM EDT |
| No, I was barefoot. | |
| Did you have any alcoholic drinks before the injury? | Question 11/02/21 5:27 PM EDT |
| No, I was stone-cold sober. It was the middle of the day. | |
| Did you use home remedies? (Clarified to Did you use home remedies for your foot?.) | Question 11/02/21 5:27 PM EDT |
| Yeah, I made sure to clean it and keep it bandaged. (Clarified to if I use home remedies for my foot.) | |
| What did you use to clean it? | Question 11/02/21 5:28 PM EDT |
| Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off. | |
| When did you go to the ER? | Question 11/02/21 5:29 PM EDT |
| I went about an hour after I fell, I think. | |
| Did you get any medication at the ER? | Question 11/02/21 5:29 PM EDT |
| Yes, they wrote me a prescription for some pain pills. | |
| Do you know the name of the pain pills? | Question 11/02/21 5:30 PM EDT |
| It’s called tramadol. | |
| What dosage of tramadol? | Question 11/02/21 5:30 PM EDT |
| I’m not 100% sure, but I think they’re 50 milligrams. | |
| How often were you taking the tramadol? | Question 11/02/21 5:30 PM EDT |
| I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON] | |
| Did tramadol relieve pain?/ | Question 11/02/21 5:31 PM EDT |
| I’ve only been taking the pain pills the ER gave me and staying off it. . . and keeping the wound clean. | |
| Has your foot bled since the injury? | Question 11/02/21 5:32 PM EDT |
| It’s not bleeding anymore. It only bled right after I scraped it. | |
| What happened after you scraped your foot? | Question 11/02/21 5:32 PM EDT |
| I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER. | |
| It is good to seek medical attention | Educate 11/02/21 5:33 PM EDT |
| OK, I understand. | |
| How effective is the pain medication? | Question 11/02/21 5:34 PM EDT |
| They only help for a few hours at a time. | |
| Am sorry to hear that. | Empathize 11/02/21 5:35 PM EDT |
| Thanks for saying that. | |
| How have you cared for the scrape? | Question 11/02/21 5:35 PM EDT |
| I made sure to clean it and just keep it bandaged. And I put Neosporin on it. | |
| How effective was the neosporin? | Question 11/02/21 5:36 PM EDT |
| Well, I had to come back to get my foot checked out even though I used the ointment. [AUDIO COMING SOON] | |
| How often have you been cleaning your scrape? | Question 11/02/21 5:37 PM EDT |
| Twice a day — every morning and every night. | |
| Great. It is good to keep it clean. | Educate 11/02/21 5:38 PM EDT |
| Sure, I think I understand what you mean. | |
| Is the wound swollen? | Question 11/02/21 5:38 PM EDT |
| Yeah, it looks swollen around the scrape. | |
| Does your scrape have an odor? | Question 11/02/21 5:39 PM EDT |
| Um, no, not that I know of… That sounds gross. | |
| Any pus? | Question 11/02/21 5:39 PM EDT |
| Yeah, there’s definitely pus. | |
| What color is the pus? | Question 11/02/21 5:40 PM EDT |
| It’s… white or maybe off-white. | |
| Is the scrape red? | Question 11/02/21 5:40 PM EDT |
| Yeah, it’s red all around the scrape. | |
| Any temperature change around the scrape? | Question 11/02/21 5:41 PM EDT |
| No. | |
| Are you having problems getting around? | Question 11/02/21 5:42 PM EDT |
| Yes! I mean, I literally can’t put weight on my foot, the pain is so sharp. | |
| Am sorry to hear that. | Question 11/02/21 5:43 PM EDT |
| My hearing is fine. | |
| Am sorry to hear that | Empathize 11/02/21 5:43 PM EDT |
| Thanks for understanding. | |
| Who has been helping you at home since you hurt your foot? | Question 11/02/21 5:44 PM EDT |
| I’m lucky living at home because my mom is around to help me, and my sister too. | |
| Do you work? |
xxxxx
| I haven’t had a mammogram. I’ve just had the exam where the doctor felt around for lumps. | ||
| Any pain in the breasts? | Question 11/02/21 7:11 PM EDT |
| No. Maybe some soreness before my period, but that seems pretty typical. | |
| Any nipple discharge? | Question 11/02/21 7:11 PM EDT |
| Uh, no, definitely not. | |
| Any nosebleed? | Question 11/02/21 7:12 PM EDT |
| No. | |
| Any chest pain? | Question 11/02/21 7:12 PM EDT |
| No, my chest feels tight when I have breathing problems, but it doesn’t hurt. | |
| Any difficulty moving your bowels? | Question 11/02/21 7:13 PM EDT |
| Not really. | |
| Any skin changes? | Question 11/02/21 7:13 PM EDT |
| Well…I guess I was noticing the other day that the skin around my neck is looking weird. Like the skin is getting darker. And my skin’s breaking out, but that’s how it is. | |
| What is your general health condition? | Question 11/02/21 7:14 PM EDT |
| Overall, my health is pretty good. I have a couple of problems, I guess, but they don’t bother me too much. | |
| Any fatigue? | Question 11/02/21 7:14 PM EDT |
| Most days I feel pretty exhausted by the end of the day…I’m tired now, too, but I think that’s just because I slept terribly. | |
| How is your sleep pattern? | Question 11/02/21 7:14 PM EDT |
| I try to be in bed by eleven or midnight, and I get up at seven or eight. | |
| Any hearing problems? | Question 11/02/21 7:15 PM EDT |
| No. | |
| Any ear discharge? | Question 11/02/21 7:15 PM EDT |
| No. | |
| Does your mother have any health problems? | Question 11/02/21 7:17 PM EDT |
| Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. | |
| Does your father have medical problems? | Question 11/02/21 7:18 PM EDT |
| Well, he passed away. But he had a couple things . . . Type 2 diabetes, like me, and high cholesterol and blood pressure. | |
| Am sorry to hear that | Empathize 11/02/21 7:18 PM EDT |
| I appreciate you saying that. | |
| When did your father pass away? | Question 11/02/21 7:18 PM EDT |
| It was last year… I guess a little over a year ago. | |
| How did you cope with your father’s death? | Question 11/02/21 7:19 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. | |
| You are lucky to have a great support system | Empathize 11/02/21 7:20 PM EDT |
| I appreciate you telling me that. | |
| What was the cause of your father’s death? | Question 11/02/21 7:21 PM EDT |
| He died in a car accident. | |
| Am sorry to hear that. | Empathize 11/02/21 7:21 PM EDT |
| Thanks for saying that. | |
| How is your paternal grandfather? | Question 11/02/21 7:22 PM EDT |
| Grandpa Jones passed away when I was really little. | |
| Did Grandpa Jones have medical problems? | Question 11/02/21 7:23 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. | |
| Does your paternal grandmother have health problems? | Question 11/02/21 7:23 PM EDT |
| She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82. | |
| great to hear that. | Empathize 11/02/21 7:24 PM EDT |
| Thanks. | |
| Your maternal grandfather’s healthy? | Question 11/02/21 7:25 PM EDT |
| Well, Poppa died five years ago. | |
| How old was your maternal grandfather? (Clarified to How old was your maternal grandfather when he passed?.) | Question 11/02/21 7:25 PM EDT |
| He was almost 80, maybe like 78 or 79? (Clarified to how old my maternal grandfather lived to be.) | |
| Your maternal grandmother’s health? | Question 11/02/21 7:26 PM EDT |
| Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. | |
| Does your brother have health issues? | Question 11/02/21 7:27 PM EDT |
| No, I don’t think so. He’s a little big, maybe. | |
| Does your sister have health issues? | Question 11/02/21 7:27 PM EDT |
| She’s pretty healthy. She has asthma but almost never has attacks. | |
| Does obesity run in your family? | Question 11/02/21 7:28 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 family history of thyroid problems? | Question 11/02/21 7:29 PM EDT |
| No, I don’t think so. | |
| Any headaches? | Question 11/02/21 7:29 PM EDT |
| Yeah, I get them a lot when I’m studying. | |
| Any loss of consciousness? | Question 11/02/21 7:30 PM EDT |
| No. | |
| Any memory loss? | Question 11/02/21 7:30 PM EDT |
| No. I mean, sometimes, I freeze up during a test, but that’s everybody, right? I have a good head for names and directions, stuff like that. | |
| Any abnormal or excess hair? (Clarified to Do you have skin abnormalities?.) | Question 11/02/21 7:30 PM EDT |
| Well . . . I guess I was noticing the other day that the skin around my neck is looking weird. The skin is getting darker. And my skin’s breaking out, but that’s how it is. (Clarified to if I have skin abnormalities.) | |
| Any stomach upsets? | Question 11/02/21 7:31 PM EDT |
| No. | |
| Measured wound: 2 cm x 1.5 cm, 2.5 mm deep | Exam Action 11/02/21 7:31 PM EDT |
| Swabbed wound and sent to lab for C & S | Exam Action 11/02/21 7:31 PM EDT |
| Cleansed and irrigated wound with normal saline and applied dry sterile dressing. | Exam Action 11/02/21 7:31 PM EDT |
| Measured wound: 2 cm x 1.5 cm, 2.5 mm deep | Exam Action 11/03/21 4:04 AM EDT |
| Swabbed wound and sent to lab for C & S | Exam Action 11/03/21 4:04 AM EDT |
| Cleansed and irrigated wound with normal saline and applied dry sterile dressing. | Exam Action 11/03/21 4:04 AM EDT |